NPIMap

Organization Active NPI

Providence Health & Services Washington

Doing business as Providence Family Medicine Chewelah

  • Rural Health Clinic/Center
  • Chewelah, WA
National Provider Identifier
1639892672
Registry record updated May 5, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PROVIDENCE HEALTH & SERVICES WASHINGTON
Doing business as
Providence Family Medicine Chewelah
Practice address
100 W South Ave
Chewelah, WA 99109-9684
Phone
(509) 935-8111
Fax
(509) 935-0970
NPI assigned
Sep 23, 2022
Last updated
May 5, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 5, 2025

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

100 W South Ave
Chewelah, WA 99109-9684

Mailing address

PO Box 31001-4114
Pasadena, CA 91110-4114
Phone (509) 935-8111

Other names 1

  • PROVIDENCE FAMILY MEDICINE CHEWELAH Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040311001453 WA Part B Supplier - Clinic/Group Practice 0345139929 Receives reassigned benefits from 946 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
O20221103000988 WA Part A Provider - Rural Health Clinic 0345139929 Practice locations: Chewelah, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639892672. Details of each certification follow.

Rural health clinic certification: CCN 503930

Legal name
PROVIDENCE HEALTH & SERVICES WASHINGTON
Doing business as
PROVIDENCE FAMILY MEDICINE CHEWELAH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 30, 2023
Last certification
Jun 30, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jan 28, 1859 in WA
Enrollment address
100 W South Ave
Chewelah, WA 99109-9684

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 7

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
50D2029352Providence Family Medicine Chewelah100 W South Ave, Chewelah, WA 99109Certificate of waiverApr 4, 2028

National Provider Directory

National Provider Directory
Tax ID family
Providence HLTH Serv Wa8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Locations

100 W South Ave
Chewelah, WA 99109
Phone (509) 684-3701

101 W 8th Ave
Ste 100L1
Spokane, WA 99204
Phone (509) 474-2880

212 E Central Ave
Ste 440
Spokane, WA 99208
Phone (509) 252-1977

217 W Cataldo Ave
Fl 2
Spokane, WA 99201
Phone (509) 624-2326

820 S McClellan St
Ste 300
Spokane, WA 99204
Phone (509) 464-7880

910 N Washington St
Spokane, WA 99201
Phone (509) 327-9831

Ownership & related parties

All disclosed owners & managing parties 25

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Diane L Hejna Individual Corporate DirectorBoard Member Jul 1, 2016
Richard S Blair Individual Corporate DirectorBoard Member Jul 1, 2016
Marvin O'Quinn Individual Corporate DirectorBoard Member Jan 1, 2024
Linda Buck Individual Corporate DirectorBoard Member Jan 1, 2025
Providence Health & Services - Washington Organization, Renton, WA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Dec 12, 2022 100%
Mary E Lyons Individual Corporate DirectorBoard Member Jul 1, 2016
Phyllis M Hughes Individual Corporate DirectorBoard Member Jan 1, 2014
Rogelio Riojas Individual Corporate DirectorBoard Member Jan 1, 2025
Sean M Douglas Individual W-2 Managing EmployeeChief Financial Executive Jan 1, 2009
James Martin Individual Corporate OfficerAssistant Treasurer Jan 13, 2023
Charles Wallace Sorenson Individual Corporate DirectorBoard Member Jan 1, 2019
Donald Wayne Anderson Individual Corporate OfficerAssistant Secretary of Enrollments Jan 1, 2017
Gregory David Hoffman Individual Corporate OfficerPresident Oct 1, 2020
Isiaah D Crawford Individual Corporate DirectorBoard Member Jan 1, 2012
Ronald G Rehn Individual W-2 Managing EmployeeChief Admin Nov 16, 2012
Donna Markham Individual Corporate DirectorBoard Member Jan 1, 2024
Michael W Murphy Individual Corporate DirectorBoard Member Jan 1, 2020
Providence Health & Services Organization, Renton, WA Corporation, Non-profit Operational/Managerial Control Dec 12, 2022
Mary Beth Kingston Individual Corporate DirectorBoard of Directors Sep 1, 2022
Carmen Green Individual W-2 Managing EmployeeChief Executive Jun 1, 2024
Eric D Sprunk Individual Corporate DirectorBoard Member Jan 1, 2022
Anna R Newsom Individual Corporate OfficerCorporate Secretary May 13, 2022
Darryl Elmouchi Individual Corporate OfficerPresident Ce Apr 1, 2025
Karin Dufault Individual Corporate DirectorBoard Member Jan 1, 2025
Providence St. Joseph Health Organization, Renton, WA Corporation, For-profit Operational/Managerial Control Dec 12, 2022

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 141

Facilities that share an organizational owner with 5% or greater ownership or operational control.

  • CP King County Wa HH, LLC

    dba Providence at Home with Compassus Home Health, King

    • Home Health Agency
    • Tukwila, WA
    • NPI 1972325983

    Providence Health & Services, Providence Health & Services - Washington, Providence St. Joseph Health

    CMS ownership
  • CP Seattle Wa Hospice, LLC

    dba Providence at Home with Compassus Hospice Care, Puget Sound

    • Community Based Hospice Care Agency
    • Tukwila, WA
    • NPI 1174345193

    Providence Health & Services, Providence Health & Services - Washington, Providence St. Joseph Health

    CMS ownership
  • CP Snohomish County Wa, LLC

    dba Providence at Home with Compassus Home Health, Snohomish County

    • Community Based Hospice Care Agency
    • Everett, WA
    • NPI 1184446221

    Providence Health & Services, Providence Health & Services - Washington, Providence St. Joseph Health

    CMS ownership
  • CP Snohomish County Wa, LLC

    dba Providence at Home with Compassus Hospice Care, Snohomish County

    • Home Health Agency
    • Everett, WA
    • NPI 1720800857

    Providence Health & Services, Providence Health & Services - Washington, Providence St. Joseph Health

    CMS ownership
  • CP Sound Wa, LLC

    dba Providence at Home with Compassus Hospice Care, Puget Sound South

    • Community Based Hospice Care Agency
    • Lacey, WA
    • NPI 1659193795

    Providence Health & Services, Providence Health & Services - Washington, Providence St. Joseph Health

    CMS ownership
  • CP Sound Wa, LLC

    dba Providence at Home with Compassus Home Health, Puget Sound South

    • Home Health Agency
    • Lacey, WA
    • NPI 1669294708

    Providence Health & Services, Providence Health & Services - Washington, Providence St. Joseph Health

    CMS ownership
  • CP Spokane Wa HH, LLC

    dba Providence at Home with Compassus Home Health, INWA

    • Home Health Agency
    • Spokane Valley, WA
    • NPI 1033931043

    Providence Health & Services, Providence Health & Services - Washington, Providence St. Joseph Health

    CMS ownership
  • CP St. Mary Wa HH, LLC

    dba Providence at Home with Compassus Home Health, Walla Walla

    • Home Health Agency
    • Walla Walla, WA
    • NPI 1730901745

    Providence Health & Services, Providence Health & Services - Washington, Providence St. Joseph Health

    CMS ownership
  • Kadlec Regional Medical Center
    • General Acute Care Hospital
    • Richland, WA
    • NPI 1972507580

    Providence Health & Services - Washington

    CMS ownership
  • Northwest Washington Rehabilitation Hospital LLC

    dba Providence Swedish Rehabilitation Hospital

    • Rehabilitation Hospital
    • Lynnwood, WA
    • NPI 1306628821

    Providence Health & Services - Washington

    CMS ownership
  • Providence Health & Services - Wa

    dba Prov Scred Hrt Med Ctr & Chlds Hos

    • General Acute Care Hospital
    • Spokane, WA
    • NPI 1144471715

    Providence Health & Services, Providence Health & Services - Washington, Providence St. Joseph Health

    CMS ownership
  • Providence Health & Services - Wa

    dba Providence St Joseph Hospital

    • Medicare Defined Swing Bed Hospital Unit
    • Chewelah, WA
    • NPI 1447402839

    Providence Health & Services, Providence Health & Services - Washington, Providence St. Joseph Health

    CMS ownership
View all 141

Practitioners & affiliated clinicians

Practitioners 87

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 87

NPI Registry JSON

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

{
    "created_epoch": "1663891200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746403200000",
    "number": "1639892672",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001-4114",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911104114",
            "telephone_number": "509-935-8111",
            "fax_number": "509-935-0970"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 W SOUTH AVE",
            "city": "CHEWELAH",
            "state": "WA",
            "postal_code": "991099684",
            "telephone_number": "509-935-8111",
            "fax_number": "509-935-0970"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES WASHINGTON",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-09-23",
        "last_updated": "2025-05-05",
        "certification_date": "2025-05-05",
        "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_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE FAMILY MEDICINE CHEWELAH",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE FAMILY MEDICINE CHEWELAH",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chewelah, WA

Sources for this page

Verify at the official NPI Registry.