Providence Medical Group SouthWest Washington – Family Medicine Physician, NPI 1174744304
Family Medicine Physician
Main info
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for Providence Medical Group SouthWest Washington
1018 Capitol Way S
Suite 300
Olympia, WA 985011212
Phone: (360) 486-6508
Fax: (360) 570-2077
Type: Location
PO BOX 31001-4114
PASADENA, CA 911104114
Phone: (877) 747-2455
Type: Mailing
3360, Southwest 87th Avenue, Raleigh West, Portland, Metro, Washington County, Oregon, 97225, United States
PORTLAND, OR 972083360
Phone: (877) 747-2455
Type: Mailing
525, Lilly Road Northeast, Olympia, Thurston County, Washington, 98506, United States
OLYMPIA, WA 98506
Phone: (360) 793-7230
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2025-10-03
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Past revalidation due date
Earliest CMS due date was 2025-11-30 (191 days ago).
Enrollment records
24
Earliest due date
2025-11-30
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| O20031211000028 | O | Clinic/Group Practice | WA | TBD |
| O20190122000790 | O | Clinic/Group Practice | CA | 2025-12-31 |
| O20190122003294 | O | Clinic/Group Practice | OR | 2025-11-30 |
| O20190124000538 | O | Clinic/Group Practice | AK | 2025-11-30 |
| O20190125000073 | O | Clinic/Group Practice | CO | TBD |
| O20200506003294 | O | Clinic/Group Practice | MT | 2026-06-30 |
| O20200825002188 | O | Clinic/Group Practice | FL | 2026-07-31 |
| O20200911001749 | O | Clinic/Group Practice | HI | 2026-09-30 |
| O20200917000759 | O | Clinic/Group Practice | MO | 2026-10-31 |
| O20201008001535 | O | Clinic/Group Practice | NY | TBD |
| O20201020000693 | O | Clinic/Group Practice | NV | TBD |
| O20201022003882 | O | Clinic/Group Practice | DC | TBD |
| O20210113000803 | O | Clinic/Group Practice | MI | TBD |
| O20210318000063 | O | Clinic/Group Practice | TX | TBD |
| O20220301002727 | O | Clinic/Group Practice | ID | TBD |
| O20221201002130 | O | Clinic/Group Practice | MN | TBD |
| O20230403001649 | O | Clinic/Group Practice | AZ | TBD |
| O20240115000063 | O | Clinic/Group Practice | IL | TBD |
| O20240610002278 | O | Clinic/Group Practice | NE | TBD |
| O20240906000368 | O | Clinic/Group Practice | WI | TBD |
| O20250214002638 | O | Clinic/Group Practice | UT | TBD |
| O20250425000364 | O | Clinic/Group Practice | NC | TBD |
| O20251001001925 | O | Clinic/Group Practice | TN | TBD |
| O20251003003319 | O | Clinic/Group Practice | NJ | TBD |
What to do next
- Verify current status on the CMS Revalidation Lookup Tool immediately.
- Complete revalidation in PECOS or contact your Medicare Administrative Contractor (MAC).
- Overdue revalidation can lead to deactivation of Medicare billing privileges.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 98501)
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