Healthcare Provider Details

I. General information

NPI: 1255582649
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - WA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2008
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5007 CLAREMONT WAY
EVERETT WA
98203-3321
US

IV. Provider business mailing address

909 N BROADWAY PBO/CREDENTIALING
EVERETT WA
98201-1409
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-7050
  • Fax: 425-258-7055
Mailing address:
  • Phone: 425-317-0246
  • Fax: 425-317-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. BARBARA SCHUMACHER
Title or Position: PRO FEE CREDENTIALING MANAGER
Credential:
Phone: 425-258-7050