Provider Demographics
NPI:1992853881
Name:PROVIDENCE ST JOSEPH MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE ST JOSEPH MEDICAL CENTER
Other - Org Name:PROV ST JOSEPH MED CTR SWB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST CORP SEC FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
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:406-883-8488
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12513282NC0060X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT27Z343OtherPTAN