| NPI | 1639279706 |
|---|---|
| Doing Business As | PROVIDENCE MEDICAL GROUP TANASBOURNE |
| Entity Type | Organization |
| Authorized Contact | DONALD W ANDERSON Dir Reimb Reg Strat/Asst Sec Enroll 425-525-5392 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X |
| Enumeration Date | 2006-09-25 |
| Last Update Date | 2020-10-02 |