Providence Health & Services - Washington
Organization Active NPI Rural Health Clinic/Center · Rochester, WA
NPI 1205931508 · NPPES record last updated May 13, 2025
Key facts
- NPI
- 1205931508
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- PROVIDENCE HEALTH & SERVICES - WASHINGTON
- Practice address
- 18313 Paulson St SW
Suite a
Rochester, WA 98579-9262 - Phone
- (360) 827-8400
- Fax
- (360) 273-7301
- NPI assigned
- Sep 13, 2006
- Organization subpart
- No
Authorized official
- Name
- Donald Wayne Anderson Jr.
- Title
- Asst Corp Sec for Enrollments
- Phone
- (425) 358-9786
Owners & managing parties with NPI records 1
Member of 1
Facilities with the same owner 141
Practitioners 25
-
Jordan M Abel, MD
-
Susan Renae Carlton, ARNP
-
Jami Larson, LICSW
-
Pooja M Patel, MD
-
Katty Raisor, ARNP
-
Andrew Paul Patel, M.D.
-
Stephanie S Looi, MD
-
Michelle L Patton, LICSW
-
Morgane Marielle Atienza, ARNP
-
Jane M. Geraci, M.D., MPH
-
Kenneth Wayne Kooser, M.D.
-
Molly Jean Martin, ARNP
-
Daniel Ray Morgenstern, ARNP
-
Darren Michael Nealis, LICSW
-
Brian D Ottesen, ARNP
-
Cullen Owen, D.O.
-
Amber L Piranio, ARNP
-
Carolyn J Price, LICSW
-
Julie Rice, ARNP
-
Christopher Schwartz, D.O.
-
James Henry Keene, M.D.
-
Samuel Seouk Joon Kim, PHARMD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in WA
Rural health clinic certification: CCN 503839
- Legal name
- PROVIDENCE HEALTH & SERVICES - WASHINGTON
- Doing business as
- PMG SW WA ROCHESTER FAM MED
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Apr 10, 1996
- Last certification
- Mar 8, 2017
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jan 28, 1859 in WA
- Enrollment address
- 18313 Paulson St. SW
Suite a
Rochester, WA 98579-9262
All disclosed owners & managing parties 23
| Name | Role | Since | Share |
|---|---|---|---|
| Diane L Hejna |
Corporate Director |
Jul 1, 2016 | |
| Richard S Blair |
Corporate Director |
Jul 1, 2016 | |
| Marvin O'Quinn |
Corporate Director |
Jan 1, 2024 | |
| Linda Buck |
Corporate Director |
Jan 1, 2025 | |
| Providence Health & Services - Washington |
5% Or Greater Direct Ownership Interest | Sep 3, 2008 | 100% |
| Operational/Managerial Control | Sep 3, 2008 | ||
| Russell J Igoe |
W-2 Managing Employee |
Nov 24, 2019 | |
| Mary E Lyons |
Corporate Director |
Jul 1, 2016 | |
| Phyllis M Hughes |
Corporate Director |
Jan 1, 2014 | |
| Rogelio Riojas |
Corporate Director |
Jan 1, 2025 | |
| James Martin |
Corporate Officer |
Jan 13, 2023 | |
| Charles Wallace Sorenson |
Corporate Director |
Jan 1, 2019 | |
| Donald Wayne Anderson |
Corporate Officer |
Jan 1, 2017 | |
| Gregory David Hoffman |
Corporate Officer |
Oct 1, 2020 | |
| Isiaah D Crawford |
Corporate Director |
Feb 1, 2012 | |
| Donna Markham |
Corporate Director |
Jan 1, 2024 | |
| Michael W Murphy |
Corporate Director |
Jan 1, 2020 | |
| Providence Health & Services |
Operational/Managerial Control | Jul 1, 2016 | |
| Other | Jul 1, 2016 | ||
| Mary Beth Kingston |
Corporate Director |
Sep 1, 2022 | |
| Eric D Sprunk |
Corporate Director |
Jan 1, 2022 | |
| Anna R Newsom |
Corporate Officer |
May 13, 2022 | |
| Darryl Elmouchi |
Corporate Officer |
Apr 1, 2025 | |
| Karin Dufault |
Corporate Director |
Jan 1, 2025 | |
| Providence St. Joseph Health |
Operational/Managerial Control | Jul 1, 2016 | |
| Other | Jul 1, 2016 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040622000640 | WA | Part B Supplier - Clinic/Group Practice | 2365427556 |
Receives reassigned benefits from 24 practitioners Practice locations: Rochester, WA |
| O20050602000450 | WA | Part a Provider - Rural Health Clinic | 2365427556 | Practice locations: Rochester, WA |
National Provider Directory
Locations
1001 Cooper Point Rd SW
Olympia, WA 98502
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist |
174400000X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
18313 Paulson St SW
Suite a
Rochester, WA 98579-9262
Mailing address
PO Box 31001-4114
Pasadena, CA 91110-4114
Phone (503) 893-7120
Other providers in Rochester, WA
- N W Pediatric Center Inc P S
- Darren Michael Nealis
- Courtney Jeanette Oliver
- Options Consulting, PLLC
- Brian D Ottesen
- Providence Health & Services - Washington
- Quixote Consulting
- Katty Raisor
- Gerardo A Ramirez Sr.
- Claudia J Randall
All providers in Rochester, WA · Rural Health Clinic/Center in Washington
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 13, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.