Provider Demographics
NPI:1821184888
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:DIR REIMB REG STRAT/ASST SEC ENROLL
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
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:
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:406-883-8255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-05
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10617282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4103103Medicaid
MT4103103Medicaid