1396814166 NPI number — TRA-MINW P S

Table of content: (NPI 1396814166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396814166 NPI number — TRA-MINW P S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRA-MINW P S
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:
TACOMA RADIOLOGICAL ASSOCIATES PS
Provider Other Organization Name Type Code:
4
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:
1396814166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3656
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-3656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-231-9211
Provider Business Mailing Address Fax Number:
253-761-4201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2502 S UNION AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-1328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-761-4200
Provider Business Practice Location Address Fax Number:
253-761-4201
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EPSHTEYN
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
253-761-4200

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CR0042 . This is a "RR MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 40700 . This is a "LABOR AND INDUSTRIES/DSHS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7820707 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P03231 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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