Healthcare Provider Details

I. General information

NPI: 1295016145
Provider Name (Legal Business Name): PROVIDENCE PHYSICIAN SERVICES CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 10/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W. 5TH AVE SUITE 307
SPOKANE WA
99204
US

IV. Provider business mailing address

PO BOX 34439
SEATTLE WA
98124-1439
US

V. Phone/Fax

Practice location:
  • Phone: 509-252-9602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL MALLORY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 425-525-6798