Provider Demographics
NPI:1891001277
Name:PROVIDENCE PHYSICIAN SERVICES CO
Entity Type:Organization
Organization Name:PROVIDENCE PHYSICIAN SERVICES CO
Other - Org Name:PROVIDENCE PEDIATRIC NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-482-2367
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:425-525-6798
Mailing Address - Fax:
Practice Address - Street 1:5901 N LINDERWOOD
Practice Address - Street 2:SUITE 126
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207
Practice Address - Country:US
Practice Address - Phone:509-489-5110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PHYSICIAN SERVICES CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty