1467631424 NPI number — ADULT & CHILD MEDICINE LLC

Table of content: (NPI 1467631424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467631424 NPI number — ADULT & CHILD MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADULT & CHILD MEDICINE LLC
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:
1467631424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1207 N 200TH ST
Provider Second Line Business Mailing Address:
SUITE # 102
Provider Business Mailing Address City Name:
SHORELINE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98133-3213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-533-1570
Provider Business Mailing Address Fax Number:
206-533-1668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1207 N 200TH ST
Provider Second Line Business Practice Location Address:
SUITE # 102
Provider Business Practice Location Address City Name:
SHORELINE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98133-3213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-533-1570
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MILMAN
Authorized Official First Name:
IRINA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
206-533-1570

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MD00042748 , 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: 2227182 . This is a "FIRST HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 6175MI . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1120534 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".