Basic Information
| Provider Information | |||||||||
| NPI: | 1891001277 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE PHYSICIAN SERVICES CO | ||||||||
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| OtherOrganizationName: | PROVIDENCE PEDIATRIC NORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34439 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255256798 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5901 N LINDERWOOD | ||||||||
| Address2: | SUITE 126 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094895110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2010 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | WALSTROM | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5094822367 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE PHYSICIAN SERVICES CO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.