Provider Demographics
NPI:1003050709
Name:PROVIDENCE HEALTH & SERVICES - WA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WA
Other - Org Name:PMG NW WA H P URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR RCM NWR PHYSICIAN DIVISION
Authorized Official - Prefix:
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-317-0284
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:425-316-5469
Mailing Address - Fax:425-316-5484
Practice Address - Street 1:4112 HARBOUR POINTE BLVD SW
Practice Address - Street 2:SUITE100
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5457
Practice Address - Country:US
Practice Address - Phone:425-347-6350
Practice Address - Fax:425-347-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8877705Medicare PIN