Provider Demographics
NPI:1619268281
Name:PROVIDENCE PHYSICIAN SERVICES CO
Entity Type:Organization
Organization Name:PROVIDENCE PHYSICIAN SERVICES CO
Other - Org Name:PMG PROVIDENCE FAMILY MEDICINE CHEWELAH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-504-1926
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 W. SOUTH AVE CHEWELAH
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109
Practice Address - Country:US
Practice Address - Phone:509-935-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PHYSICIAN SERVICES CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty