Provider Demographics
NPI:1538311287
Name:PROVIDENCE HEALTH & SERVICES-WA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES-WA
Other - Org Name:NW HEART & LUNG SURGICAL ASSOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SEC ENROLLMT/DIR REIMB REG
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-3012
Mailing Address - Country:US
Mailing Address - Phone:509-456-0262
Mailing Address - Fax:425-276-3215
Practice Address - Street 1:62 W 7TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2321
Practice Address - Country:US
Practice Address - Phone:509-456-0262
Practice Address - Fax:509-462-5059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600503828208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8878011OtherMEDICARE PTAN
WAG8878024OtherMEDICARE PTAN