Basic Information
| Provider Information | |||||||||
| NPI: | 1306097126 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICES - WASHINGTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE MEDICAL GROUP SOUTHEAST WASHINGTON IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34439 | ||||||||
| Address2: | MAILING / CREDENTIALING | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095298905 | ||||||||
| FaxNumber: | 5095268402 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W POPLAR STREET | ||||||||
| Address2: | PMG SE WA IMAGING | ||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225850 | ||||||||
| FaxNumber: | 5095268402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | PARENTEAU | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5095225890 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HEALTH & SERVICES - WASHINGTON | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 191431900 | 01 | WA | L&I FEDERAL | OTHER | 222605 | 01 | WA | L&I STATE | OTHER | 7138118 | 05 | WA | MEDICAID |