Provider Demographics
NPI:1164410254
Name:PROVIDENCE HEALTH CARE
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH CARE
Other - Org Name:MOUNT CARMEL HOSPITAL-SURGEON GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-685-6032
Mailing Address - Street 1:1200 E COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-3354
Mailing Address - Country:US
Mailing Address - Phone:509-684-3701
Mailing Address - Fax:509-684-5817
Practice Address - Street 1:1200 E COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-3354
Practice Address - Country:US
Practice Address - Phone:509-684-3701
Practice Address - Fax:509-684-5817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8901822OtherL & I
WA8912288OtherCRIME VICTIMS
WA7108863Medicaid
AB29093Medicare ID - Type Unspecified