| NPI | 1881191948 |
|---|---|
| Doing Business As | PROVIDENCE MEDICAL GROUP MT - MDPP |
| Entity Type | Organization |
| Authorized Contact | DONALD WAYNE ANDERSON Asst Sec For Enrollment/Dir Reimb A 425-525-5392 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X |
| Enumeration Date | 2018-04-06 |
| Last Update Date | 2018-04-06 |