Basic Information
| Provider Information | |||||||||
| NPI: | 1316041056 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE EVERETT MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 N BROADWAY | ||||||||
| Address2: | PBO CREDENTIALING | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253170699 | ||||||||
| FaxNumber: | 4252614051 | ||||||||
| Practice Location | |||||||||
| Address1: | 1321 COLBY AVE | ||||||||
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| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252612000 | ||||||||
| FaxNumber: | 4252614051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 09/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | KOBAYASHI | ||||||||
| AuthorizedOfficialFirstName: | JOYCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR REVENUE CYCLE MGMT NWSA | ||||||||
| AuthorizedOfficialTelephone: | 4253170186 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H-084 | WA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | H-084 | 01 | WA | HOSPITAL'S LICENSE # | OTHER | 3309606 | 05 | WA | MEDICAID |