1376761775 NPI number — WESTERN WASHINGTON MEDICAL GROUP, INC PS

Table of content: (NPI 1376761775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376761775 NPI number — WESTERN WASHINGTON MEDICAL GROUP, INC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN WASHINGTON MEDICAL GROUP, INC 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:
WESTERN WA MEDICAL GROUP DEPT OF ORTHOPEDICS
Provider Other Organization Name Type Code:
3
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:
1376761775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3726 BROADWAY
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98201-3787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-317-9119
Provider Business Mailing Address Fax Number:
425-317-9118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3726 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201-3788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-317-9119
Provider Business Practice Location Address Fax Number:
425-317-9118
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCGINNIS
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PM SYSTEM ADMINISTRATOR
Authorized Official Telephone Number:
425-740-4148

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  601474013 , 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: 0036257 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CQ2138 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7067648 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0728350005 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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