Provider Demographics
NPI:1639258130
Name:PROVIDENCE PHYSICIAN GROUP
Entity Type:Organization
Organization Name:PROVIDENCE PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BEEGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-316-5470
Mailing Address - Street 1:909 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1409
Mailing Address - Country:US
Mailing Address - Phone:425-317-0257
Mailing Address - Fax:425-317-0291
Practice Address - Street 1:12800 BOTHELL EVERETT HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6642
Practice Address - Country:US
Practice Address - Phone:425-316-5150
Practice Address - Fax:425-316-5153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7095367Medicaid
WAGAB08328Medicare PIN