1215023940 NPI number — LAKEWOOD SURGICAL UROLOGY PS

Table of content: (NPI 1215023940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215023940 NPI number — LAKEWOOD SURGICAL UROLOGY PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEWOOD SURGICAL UROLOGY PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215023940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 97115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98497-0115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-588-7911
Provider Business Mailing Address Fax Number:
253-984-6774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11306 BRIDGEPORT WAY SW
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98499-3005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-581-7000
Provider Business Practice Location Address Fax Number:
253-984-6774
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAK
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
253-581-7000

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  MD00044997 , 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)





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