Provider Demographics
NPI:1073699922
Name:PROVIDENCE PHYSICIAN GROUP
Entity Type:Organization
Organization Name:PROVIDENCE PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRO FEE CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUMACHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-5121
Mailing Address - Street 1:909 N BROADWAY
Mailing Address - Street 2:PBO/CREDENTIALING
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1409
Mailing Address - Country:US
Mailing Address - Phone:425-317-0246
Mailing Address - Fax:425-317-0291
Practice Address - Street 1:2320 RUCKER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-2723
Practice Address - Country:US
Practice Address - Phone:425-259-5121
Practice Address - Fax:425-252-1322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB 08328Medicare PIN