Basic Information
| Provider Information | |||||||||
| NPI: | 1386895886 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES - WASHINGTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE ST MARY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 273 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098973320 | ||||||||
| FaxNumber: | 5095225789 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098973320 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 04/23/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST SEC ENROLLMENT/DIR REIMB ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H-050 | WA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 008478 | 01 | WA | L&I STATE | OTHER | 201716900 | 01 | WA | L&I FEDERAL | OTHER | 3303104 | 05 | WA | MEDICAID |