Provider Demographics
NPI:1982856886
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE MEDICAL GROUP SOUTHEAST WASHINGTON RADIATION ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARENTEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-522-5890
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:MAILING / CREDENTIALING
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:509-529-8905
Mailing Address - Fax:509-526-8402
Practice Address - Street 1:401 W POPLAR STREET
Practice Address - Street 2:PMG SE WA RADIATION ONCOLOGY
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2846
Practice Address - Country:US
Practice Address - Phone:509-522-5700
Practice Address - Fax:509-526-8402
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-22
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-0502085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8877672Medicare PIN