Provider Demographics
NPI:1184654139
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:425-347-6330
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 1:4112 HARBOUR POINTE BLVD SW
Practice Address - Street 2:SUITE 100
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5457
Practice Address - Country:US
Practice Address - Phone:425-347-6330
Practice Address - Fax:425-347-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & 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
WA7126964Medicaid
WAGAB08328Medicare PIN