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DSH500014Q PROVIDENCE HEALTH & SERVICES - WASHINGTON (Active)
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Main Details
Name
PROVIDENCE HEALTH & SERVICES - WASHINGTON
Subdivision Name
Radiation Oncology
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH500014Q
Medicare Provider Number
500014
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/9/2019
Participating Start Date
7/1/2019
Participating Approval Date
5/31/2019
Last Recertification Date
8/27/2024
Contacts
Authorizing Official
Providence Health & Services Washington
Scott Combs, CFO
(425) 261-4044
Primary Contact
Providence Health & Services Washington
Eric Werttemberger, Director of Pharmacy
(425) 261-3530
Addresses
Street Address
1717 13th Street, Suite #2
Everett, WA 98201
Billing Address
Providence St. Joseph Health
PO Box 31263
Salt Lake City, UT 84131
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date (07/01/2016) until terminated effective date (07/01/2017), reinstatement effective date (07/01/2019)
05/15/2019
May 2025
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