Basic Information
| Provider Information | |||||||||
| NPI: | 1598783318 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE EVERETT MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | PROVIDENCE MATERNAL-FETAL MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 N BROADWAY | ||||||||
| Address2: | PBO CREDENTIALING | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253170699 | ||||||||
| FaxNumber: | 4253170291 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 PACIFIC AVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253046165 | ||||||||
| FaxNumber: | 4253046162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 09/23/2008 | ||||||||
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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 | 207VM0101X | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7001738 | 05 | WA | MEDICAID | 7112279 | 01 | WA | DSHS GENETIC COUNSELORS | OTHER | 7124902 | 05 | WA | MEDICAID |