Provider Demographics
NPI:1508058520
Name:PROVIDENCE HEALTH SYSTEM WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM WASHINGTON
Other - Org Name:PROVIDENCE CENTRALIA HOSPITAL PT
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO SWSA REGION
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:RISSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-493-5701
Mailing Address - Street 1:914 S SCHEUBER RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9027
Mailing Address - Country:US
Mailing Address - Phone:360-736-2803
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:98531-9027
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:2007-08-14
Last Update Date:2007-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7061559Medicaid
WAG8854460Medicare PIN