Provider Demographics
NPI:1366658858
Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Other - Org Name:PROVIDENCE KODIAK ISLAND MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-3362
Mailing Address - Street 1:1915 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1915 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6602
Practice Address - Country:US
Practice Address - Phone:907-486-3281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK309115313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHS10LTMedicaid