Provider Demographics
NPI:1265967137
Name:PROVIDENCE IMAGING CENTER
Entity type:Organization
Organization Name:PROVIDENCE IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY OF 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 4567
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4567
Mailing Address - Country:US
Mailing Address - Phone:907-212-3151
Mailing Address - Fax:
Practice Address - Street 1:3340 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-212-3151
Practice Address - Fax:907-212-5828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK48375261QR0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0207XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile Mammography