Basic Information
| Provider Information | |||||||||
| NPI: | 1881907715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICES WASHINGTON | ||||||||
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| OtherOrganizationName: | PROVIDENCE SPOKANE HEART INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 331 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094558820 | ||||||||
| FaxNumber: | 5094554150 | ||||||||
| Practice Location | |||||||||
| Address1: | 62 W 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094743278 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2010 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST SECT FOR ENROLLMENT / DIR REGU | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.