NPIMap

Organization Active NPI

Providence Health & Services Washington

Doing business as Providence Health & Services Washington (PMG SE WA) - Express Care

  • General Practice Physician
  • College Place, WA
National Provider Identifier
1023563897
Registry record updated May 6, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
Legal business name
PROVIDENCE HEALTH & SERVICES WASHINGTON
Doing business as
Providence Health & Services Washington (PMG SE WA) - Express Care
Practice address
1705 SE Meadowbrook Blvd
Suite 2
College Place, WA 99324-1756
Phone
(509) 987-2450
NPI assigned
Aug 22, 2016
Last updated
May 6, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 6, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Donald W Anderson Jr.
Title
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Physician 208D00000X Primary
Clinic/Center 261Q00000X

Addresses

Primary practice location

1705 SE Meadowbrook Blvd
Suite 2
College Place, WA 99324-1756

Mailing address

PO Box 32
Liberty Lake, WA 99019-0032

Other names 1

  • Providence Health & Services Washington (PMG SE WA) - Express Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20081223000478 WA Part B Supplier - Clinic/Group Practice 2860552973 Receives reassigned benefits from 295 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1471824000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746489600000",
    "number": "1023563897",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 32",
            "city": "LIBERTY LAKE",
            "state": "WA",
            "postal_code": "990190032"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1705 SE MEADOWBROOK BLVD",
            "address_2": "SUITE 2",
            "city": "COLLEGE PLACE",
            "state": "WA",
            "postal_code": "993241756",
            "telephone_number": "509-987-2450"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES WASHINGTON",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-08-22",
        "last_updated": "2025-05-06",
        "certification_date": "2025-05-06",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY OF ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence Health & Services Washington (PMG SE WA) - Express Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in College Place, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.