Basic Information
Provider Information | |||||||||
NPI: | 1871515429 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROVIDENCE PHYSICIAN GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 909 N BROADWAY | ||||||||
Address2: | PBO/CREDENTIALING | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982011409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253170246 | ||||||||
FaxNumber: | 4253170291 | ||||||||
Practice Location | |||||||||
Address1: | 1330 ROCKEFELLER AVE | ||||||||
Address2: | SUITE 230 | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982011684 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252614925 | ||||||||
FaxNumber: | 4252614932 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2006 | ||||||||
LastUpdateDate: | 03/11/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHUMACHER | ||||||||
AuthorizedOfficialFirstName: | BARBARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRO FEE CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4252614925 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 363LG0600X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 2471B0102X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Bone Densitometry | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 7095417 | 05 | WA |   | MEDICAID |