Basic Information
| Provider Information | |||||||||
| NPI: | 1811942758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICE - WASHINGTON | ||||||||
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| OtherOrganizationName: | PROVIDENCE IMAGING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34439 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255256778 | ||||||||
| FaxNumber: | 4255256700 | ||||||||
| Practice Location | |||||||||
| Address1: | 908 S SCHEUBER RD | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985319027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603308880 | ||||||||
| FaxNumber: | 3603308812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 12/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | QUINN | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PAYOR CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4255256715 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471B0102X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Bone Densitometry | 2471M2300X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Mammography | 2471C3402X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography |
ID Information
| ID | Type | State | Issuer | Description | 7124043 | 05 | WA | MEDICAID |