Provider Demographics
NPI:1245557917
Name:PROVIDENCE PHYSICIAN SERVICES CO
Entity type:Organization
Organization Name:PROVIDENCE PHYSICIAN SERVICES CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:ANSELMO
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-474-6616
Mailing Address - Street 1:101 W 8TH AVE
Mailing Address - Street 2:MOTHER GAMELIN CENTER, 3RD FLOOR
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:518 CLAY STREET
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109
Practice Address - Country:US
Practice Address - Phone:509-684-3701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PHYSICIAN SERVICES CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-21
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty