Provider Demographics
NPI:1578865887
Name:PROVIDENCE PHYSICIAN SERVICES CO
Entity Type:Organization
Organization Name:PROVIDENCE PHYSICIAN SERVICES CO
Other - Org Name:PROVIDENCE CENTER FOR CONGENITAL HEART DISEASE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:ANSELMO
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-474-6616
Mailing Address - Street 1:101 W 8TH AVE
Mailing Address - Street 2:STE 4300
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:STE 4300
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-747-6707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PHYSICIAN SERVICES CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-19
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty