1184891723 NPI number — MOLLY RUTH PETRIE LMP

Table of content: MOLLY RUTH PETRIE LMP (NPI 1184891723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184891723 NPI number — MOLLY RUTH PETRIE LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRIE
Provider First Name:
MOLLY
Provider Middle Name:
RUTH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TURNER
Provider Other First Name:
MOLLY
Provider Other Middle Name:
RUTH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184891723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2808
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99220-2800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-688-6702
Provider Business Mailing Address Fax Number:
509-688-6792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3010 S SOUTHEAST BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99223-3541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-533-1000
Provider Business Practice Location Address Fax Number:
509-533-1838
Provider Enumeration Date:
05/13/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA00024214 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1154414761 . This is a "COLUMBIA MEDICAL ASSOCIATES GROUP NPI NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".