Basic Information
| Provider Information | |||||||||
| NPI: | 1952500209 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES WASHINGTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE CENTRALIA HOSPITAL - PHYSIATRY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 1800 COOKS HILL RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | CENTRALIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985319072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603308626 | ||||||||
| FaxNumber: | 3608077983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| 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 | 261QX0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 7058589 | 05 | WA | MEDICAID |