Provider Demographics
NPI:1669655528
Name:PROVIDENCE ST JOSEPH MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE ST JOSEPH MEDICAL CENTER
Other - Org Name:PROV ST JOSEPH MED CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SEC FOR ENROLLMENT/DIR REIMB S
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 262
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0262
Mailing Address - Country:US
Mailing Address - Phone:406-883-5377
Mailing Address - Fax:
Practice Address - Street 1:6 13TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-5315
Practice Address - Country:US
Practice Address - Phone:406-883-5377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009912Medicare PIN