Provider Demographics
NPI:1093956278
Name:PROVIDENCE HEALTH & SERVICES- WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES- WASHINGTON
Other - Org Name:PROVIDENCE MEDICAL GROUP ALASKA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SEC ENROLLMT/DIR REIMB ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 4105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4105
Mailing Address - Country:US
Mailing Address - Phone:866-907-1068
Mailing Address - Fax:425-917-9141
Practice Address - Street 1:3200 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4615
Practice Address - Country:US
Practice Address - Phone:907-212-6002
Practice Address - Fax:907-212-8340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020543Medicaid
AK1020543Medicaid