MEDICARE: PROVIDENCE HEALTH & SERVICES - WASHINGTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist
2	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1205931508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HEALTH & SERVICES - WASHINGTON

Provider Business Mailing Address
First Line	:	PO BOX 31001-4114
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91110-4114
Country	:	US
Telephone Number	:	503-893-7120
Fax Number	:	425-276-3215

Provider Business Practice Location Address
First Line	:	18313 PAULSON ST SW
Second Line	:	SUITE A
City	:	ROCHESTER
State	:	WA
Zip	:	98579-9262
Country	:	US
Telephone Number	:	360-827-8400
Fax Number	:	360-273-7301

Authorized Official
Title or Position	:	ASST CORP SEC FOR ENROLLMENTS
Name	:	DONALD WAYNE ANDERSON JR.
Credential	:
Telephone Number	:	425-358-9786

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	05/13/2025

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