Provider Demographics
NPI:1215225099
Name:PROVIDENCE HEALTH & SERVICES-WA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES-WA
Other - Org Name:PMG NW WA MIDWIFERY MONROLE
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:425-316-5439
Mailing Address - Fax:425-316-5484
Practice Address - Street 1:14692 179TH AVE SE
Practice Address - Street 2:STE 800
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1162
Practice Address - Country:US
Practice Address - Phone:360-794-7994
Practice Address - Fax:360-805-4786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8877705Medicare PIN