Provider Demographics
NPI: | 1831146968 |
---|---|
Name: | PROVIDENCE PHYSICIAN SERVICES CO. |
Entity Type: | Organization |
Organization Name: | PROVIDENCE PHYSICIAN SERVICES CO. |
Other - Org Name: | PMG E WA |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CFO |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | DAN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | HARRIS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 206-628-2550 |
Mailing Address - Street 1: | PO BOX 462 |
Mailing Address - Street 2: | |
Mailing Address - City: | LIBERTY LAKE |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 99019-0462 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 509-474-2072 |
Mailing Address - Fax: | 509-474-6606 |
Practice Address - Street 1: | 101 W 8TH AVE |
Practice Address - Street 2: | MOTHER GAMELIN CENTER 3RD FLR |
Practice Address - City: | SPOKANE |
Practice Address - State: | WA |
Practice Address - Zip Code: | 99204-2307 |
Practice Address - Country: | US |
Practice Address - Phone: | 509-474-2072 |
Practice Address - Fax: | 509-474-6606 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-05-26 |
Last Update Date: | 2014-10-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
103T00000X, 207RN0300X, 207RP1001X, 207VM0101X, 208000000X, 2080P0006X, 2080P0205X, 2080P0206X, 2084N0400X, 2084N0402X, 2084P0800X, 208600000X, 2086S0120X, 2086S0122X | ||
WA | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
No | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207VM0101X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2080P0006X | Allopathic & Osteopathic Physicians | Pediatrics | Developmental - Behavioral Pediatrics | Group - Multi-Specialty |
No | 2080P0205X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | Group - Multi-Specialty |
No | 2080P0206X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | Group - Multi-Specialty |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 2084N0402X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 2086S0120X | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | Group - Multi-Specialty |
No | 2086S0122X | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AB32999 | Medicare PIN |