Provider Demographics
NPI:1205931508
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST CORP SEC FOR ENROLLMENTS
Authorized Official - Prefix:
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:425-358-9786
Mailing Address - Street 1:PO BOX 31001-4114
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-4114
Mailing Address - Country:US
Mailing Address - Phone:503-893-7120
Mailing Address - Fax:425-276-3215
Practice Address - Street 1:18313 PAULSON ST SW
Practice Address - Street 2:SUITE A
Practice Address - City:ROCHESTER
Practice Address - State:WA
Practice Address - Zip Code:98579-9262
Practice Address - Country:US
Practice Address - Phone:360-827-8400
Practice Address - Fax:360-273-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7088495OtherRURAL MEDICAID
WAGAB19139OtherMEDICARE B
WADA4754OtherRR MEDICARE
WADA4754OtherRR MEDICARE
WA503839Medicare Oscar/Certification