Provider Demographics
NPI:1417191057
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE SMMC UROLOGY DME
Other - Org Type:Other Name
Authorized Official - Title/Position:RCM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLUMBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-522-5906
Mailing Address - Street 1:209 W POPLAR ST
Mailing Address - Street 2:PO BOX 1477
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2828
Mailing Address - Country:US
Mailing Address - Phone:509-522-5906
Mailing Address - Fax:509-522-5789
Practice Address - Street 1:301 W POPLAR ST
Practice Address - Street 2:SUITE 50
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2858
Practice Address - Country:US
Practice Address - Phone:509-522-5832
Practice Address - Fax:509-522-5516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHAC.FS.00000050208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty