| NPI | 1235479643 |
|---|---|
| Doing Business As | PROVIDENCE MEDICAL GROUP SPORTS CARE |
| Entity Type | Organization |
| Authorized Contact | DONALD WAYNE ANDERSON Asst Sec For Enrollment/Dir Reimb 425-276-3215 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Additional Taxonomies | 207R00000X Internal Medicine |
| 207RS0010X Internal Medicine, Sports Medicine | |
| Enumeration Date | 2013-02-21 |
| Last Update Date | 2021-08-20 |