Basic Information
| Provider Information | |||||||||
| NPI: | 1164724308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICES-WASHINGTON | ||||||||
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| OtherOrganizationName: | PROVIDENCE CARDIOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 LILLY RD NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604138525 | ||||||||
| FaxNumber: | 3604138800 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 LILLY RD NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604138525 | ||||||||
| FaxNumber: | 3604138800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2010 | ||||||||
| LastUpdateDate: | 11/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | NIZOLEK | ||||||||
| AuthorizedOfficialFirstName: | WILLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3604138525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.