Basic Information
| Provider Information | |||||||||
| NPI: | 1366472508 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANCISCAN HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FRANCISCAN HOSPICE AND PALLIATIVE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 BRIDGEPORT WAY W | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984664614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535347000 | ||||||||
| FaxNumber: | 2536717099 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 BRIDGEPORT WAY W | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984664614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535347000 | ||||||||
| FaxNumber: | 2536717099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 05/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | FITZGERALD | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCIAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2535524105 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRANCISCAN HEALTH SYSTEM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7132491 | 05 | WA | MEDICAID | 0205743 | 01 | WA | STATE L&I | OTHER | 8940688 | 01 | WA | CRIME VICTIMS | OTHER |