Basic Information
| Provider Information | |||||||||
| NPI: | 1982789954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE EVERETT MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | PROVIDENCE NICU | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 N BROADWAY | ||||||||
| Address2: | PBO/CREDENTIALING | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253170264 | ||||||||
| FaxNumber: | 4253170291 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 PACIFIC AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253046040 | ||||||||
| FaxNumber: | 4253046045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 09/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | KOBAYASHI | ||||||||
| AuthorizedOfficialFirstName: | JOYCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR REVENUE CYCLE MGMT NWSA | ||||||||
| AuthorizedOfficialTelephone: | 4253170186 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | WA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 261QM2500X | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 363LN0005X | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 7001738 | 05 | WA | MEDICAID | 9620998 | 05 | WA | MEDICAID |