Basic Information
| Provider Information | |||||||||
| NPI: | 1093956278 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES WASHINGTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE MEDICAL GROUP ALASKA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4105 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669071068 | ||||||||
| FaxNumber: | 4259179141 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 PROVIDENCE DR | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072126002 | ||||||||
| FaxNumber: | 9072128340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST SEC ENROLLMT/DIR REIMB ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207RC0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1020543 | 05 | AK | MEDICAID |