Provider Demographics
NPI:1346333671
Name:PROVIDENCE HEALTH SYSTEM-WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM-WASHINGTON
Other - Org Name:PEDIATRIC SURGEONS OF ALASKA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PARRISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-261-3082
Mailing Address - Street 1:PO BOX 196276
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99519-6276
Mailing Address - Country:US
Mailing Address - Phone:907-565-6522
Mailing Address - Fax:907-565-6592
Practice Address - Street 1:3340 PROVIDENCE DR
Practice Address - Street 2:SUITE A451
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4616
Practice Address - Country:US
Practice Address - Phone:907-563-1588
Practice Address - Fax:907-563-1589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK437323208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG086Medicaid