Provider Demographics
NPI:1740566173
Name:PROVIDENCE PHYSICIAN SERVICES CO
Entity type:Organization
Organization Name:PROVIDENCE PHYSICIAN SERVICES CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CRED. SPECIALIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-6798
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 1:212 CENTRAL AVE SUITE 440
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208
Practice Address - Country:US
Practice Address - Phone:425-525-6798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PHYSICIAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty