Provider Demographics
NPI:1659558476
Name:PROVIDENCE HEALTH CARE
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH CARE
Other - Org Name:NORTHWEST HEART AND LUNG SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-474-3040
Mailing Address - Street 1:910 W 5TH AVE
Mailing Address - Street 2:STE 380
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2966
Mailing Address - Country:US
Mailing Address - Phone:509-456-0262
Mailing Address - Fax:509-624-8049
Practice Address - Street 1:122 W 7TH AVE
Practice Address - Street 2:STE 330
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2349
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:2008-01-23
Last Update Date:2008-05-12
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
WA7294903Medicaid
WA8870848OtherMEDICARE PTAN
DG9549OtherRAILROAD MEDICARE
ID1370069OtherMEDICARE PTAN