Provider Demographics
NPI:1194930313
Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PAYOR CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-6715
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:425-525-6778
Mailing Address - Fax:425-525-6700
Practice Address - Street 1:8645 MARTIN WAY E
Practice Address - Street 2:BLDG 2
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-5800
Practice Address - Country:US
Practice Address - Phone:360-923-4600
Practice Address - Fax:360-923-4663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA600 672 503OtherTAX REGSTRATION NUMBER
WA8943381OtherL&I CRIME VICTIMS
WA342 006 812OtherUNIFIED BUSINESS ID #
WA215633OtherL&I
WA7129661Medicaid
WAG8856931Medicare PIN