Provider Demographics
NPI:1790889400
Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Other - Org Name:PROVIDENCE KODIAK ISLAND MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:MR
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 1:1915 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6602
Mailing Address - Country:US
Mailing Address - Phone:907-486-3281
Mailing Address - Fax:907-486-9546
Practice Address - Street 1:1915 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6602
Practice Address - Country:US
Practice Address - Phone:907-486-3281
Practice Address - Fax:907-486-9546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK309115314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHS10SBMedicaid
AK02-Z306Medicare ID - Type UnspecifiedMEDICARE SWB PROVIDER #