Provider Demographics
NPI:1376624981
Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Other - Org Name:PROVIDENCE CENTRALIA HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR REIMBURSEMENT ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 3380
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:914 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531
Practice Address - Country:US
Practice Address - Phone:360-736-2803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA05478OtherL&I PROVIDER NUMBER
WA105OtherPREMERA BLUE CROSS
WAPR5896OtherREGENCE IP PROVIDER NUMBE
WAPR9896OtherREGENCE OP PROVIDER NUMBE
WA3302205Medicaid
WA3302205Medicaid