NPIMap

Organization Active NPI

Providence Health & Services - Washington

Doing business as Providence Medical Group Southeast Washington Neurosurgery

  • Neurological Surgery Physician
  • Walla Walla, WA
National Provider Identifier
1760636690
Registry record updated May 7, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Neurological Surgery PhysicianTaxonomy code 207T00000X
License
H-050 Issued in WA
Legal business name
PROVIDENCE HEALTH & SERVICES - WASHINGTON
Doing business as
Providence Medical Group Southeast Washington Neurosurgery
Practice address
301 W Poplar St Ste 50
Walla Walla, WA 99362-2800
Phone
(509) 522-1030
Fax
(509) 526-8402
NPI assigned
Nov 5, 2008
Last updated
May 7, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
PROVIDENCE HEALTH & SERVICES - WASHINGTONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 7, 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
Neurological Surgery PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207T00000X H-050 WA Primary

Addresses

Primary practice location

301 W Poplar St Ste 50
Walla Walla, WA 99362-2800

Mailing address

PO Box 31001-4114
Pasadena, CA 91110-4114

Other names 1

  • Providence Medical Group Southeast Washington Neurosurgery 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
Tax ID family
Providence Health Service-17 organizations share this tax ID, including this one
Part of
Providence Health Service-

Other organizations with this tax ID 16

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

View all 16

Practitioners & affiliated clinicians

Practitioners 48

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 48

NPI Registry JSON

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

{
    "created_epoch": "1225843200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746576000000",
    "number": "1760636690",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "301 W POPLAR ST STE 50",
            "city": "WALLA WALLA",
            "state": "WA",
            "postal_code": "993622800",
            "telephone_number": "509-522-1030",
            "fax_number": "509-526-8402"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - WASHINGTON",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HEALTH & SERVICES - WASHINGTON",
        "enumeration_date": "2008-11-05",
        "last_updated": "2025-05-07",
        "certification_date": "2025-05-07",
        "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": "207T00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Neurological Surgery",
            "state": "WA",
            "license": "H-050",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence Medical Group Southeast Washington Neurosurgery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Walla Walla, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 7, 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.