Basic Information
| Provider Information | |||||||||
| NPI: | 1538377957 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE EVERETT MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | PROVIDENCE EVERETT MEDICAL LABS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2670 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992202670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007528994 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1321 COLBY AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007528994 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 10/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | KOBAYASHI | ||||||||
| AuthorizedOfficialFirstName: | JOYCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR REVENUE CYCLE MGMT NWSA | ||||||||
| AuthorizedOfficialTelephone: | 4253170186 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | H-084 | WA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 7000177 | 05 | WA | MEDICAID |