Provider Demographics
NPI:1912158023
Name:PROVIDENCE HEALTH & SERVICES - WA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WA
Other - Org Name:PMG NW WA RECONSTRUCTIVE & PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR REIMB REGULATORY STRATEGY
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:425-525-5392
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-399-2983
Mailing Address - Fax:
Practice Address - Street 1:12800 BOTHELL EVERETT HWY
Practice Address - Street 2:SUITE 260
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6642
Practice Address - Country:US
Practice Address - Phone:425-316-5080
Practice Address - Fax:425-316-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G8877705Medicare Oscar/Certification