1194919829 NPI number — PODIATRIC PHYSICIANS AND SURGEOANS PS

Table of content: (NPI 1194919829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194919829 NPI number — PODIATRIC PHYSICIANS AND SURGEOANS PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PODIATRIC PHYSICIANS AND SURGEOANS 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:
DR RONALD KRIVOSHA
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:
1194919829
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 MADISON ST
Provider Second Line Business Mailing Address:
SUITE 1120
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98104-3558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-447-0302
Provider Business Mailing Address Fax Number:
206-681-5951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 MADISON ST
Provider Second Line Business Practice Location Address:
SUITE 1120
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98104-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-447-0302
Provider Business Practice Location Address Fax Number:
206-682-5951
Provider Enumeration Date:
09/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KRIVOSHA
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
206-447-0302

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  POOOO177 , 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: 1010701 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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