Provider Demographics
NPI:1588855548
Name:PROVIDENCE HEALTHCARE
Entity Type:Organization
Organization Name:PROVIDENCE HEALTHCARE
Other - Org Name:ST JOSEPH HOSPITAL ER PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-232-1177
Mailing Address - Street 1:910 N WASHINGTON ST
Mailing Address - Street 2:STE 209
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2202
Mailing Address - Country:US
Mailing Address - Phone:509-232-1145
Mailing Address - Fax:509-232-1165
Practice Address - Street 1:500 E WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109-9523
Practice Address - Country:US
Practice Address - Phone:509-935-8211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTHCARE DBA ST JOSEPHS HOSPITAL ER PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000077282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000077OtherFACILITY ID
WA7031479Medicaid