Provider Demographics
NPI:1992083216
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:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-6798
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 S MCCLELLAN, SUITE 300
Practice Address - Street 2:PROVIDENCE ORTHOPEDIC SPECIALTIES
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204
Practice Address - Country:US
Practice Address - Phone:509-464-7880
Practice Address - Fax:509-464-7961
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PHYSICIAN SERVICES CO.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty