PROVIDENCE HEALTH & SERVICES- WASHINGTON

Provider Demographics

• NPI: 1497752091
• Name: PROVIDENCE HEALTH & SERVICES- WASHINGTON
• Entity Type: Organization
• Organization Name: PROVIDENCE HEALTH & SERVICES- WASHINGTON
• Other - Org Name: PROVIDENCE ST LUKES REHABILITATION MEDICAL CENTER
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: ASST SEC FOR ENROLLMENT/DIR REIMB S
• Authorized Official - Prefix: MR
• Authorized Official - First Name: DONALD
• Authorized Official - Middle Name: WAYNE
• Authorized Official - Last Name: ANDERSON
• Authorized Official - Suffix: JR
• Authorized Official - Phone: 425-525-5392
• Mailing Address - Street 1: PO BOX 131
• Mailing Address - City: LIBERTY LAKE
• Mailing Address - State: WA
• Mailing Address - Zip Code: 99019-0131
• Mailing Address - Country: US
• Mailing Address - Phone: 509-473-6000
• Mailing Address - Fax: 509-232-8392
• Practice Address - Street 1: 711 S COWLEY ST
• Practice Address - City: SPOKANE
• Practice Address - State: WA
• Practice Address - Zip Code: 99202-1330
• Practice Address - Country: US
• Practice Address - Phone: 509-473-6000
• Practice Address - Fax: 509-473-6097
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2005-06-28
• Last Update Date: 2023-07-20

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	283X00000X	Hospitals	Rehabilitation Hospital
No	282N00000X	Hospitals	General Acute Care Hospital

Provider Identifiers

State	Identifier ID	ID Type	Issuer
WA	0057064	Other	LABOR & INDUSTRY PAIN CLI
WA	0110161	Other	LABOR & INDUSTRY VOC
WA	178006	Other	LABOR & INDUSTRY COHE
WA	0057625	Other	LABOR AND INDUSTRIES
ID	000010013358	Other	REGENCE BLUE SHIELD OF ID
WA	149245	Other	LABOR & INDUSTRIE PROF
WA	A004	Other	TRICARE PROFESSIONAL
WA	10160	Other	GROUP HEALTH
WA	ST3555	Other	ASURIS -837I
WA	3200284	Medicaid
MT	41-0397	Medicaid
WA	174405	Other	LABOR & INDUSTRY COHE
WA	CI9477	Other	MEDICARE RAILROAD
WA	163548	Other	LABOR & INDUSTRIE GROUP
WA	192165500	Other	LABOR & INDUSTRY FEDERAL
ID	3276800	Medicaid
WA	7082530	Medicaid
WA	ST4835	Other	ASURIS - 837P
WA	3200284	Medicaid
ID	000010013358	Other	REGENCE BLUE SHIELD OF ID
WA	174405	Other	LABOR & INDUSTRY COHE