1205015112 NPI number — PACIFIC NORTHWEST UROGYNECOLOGY PLLC

Table of content: (NPI 1205015112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205015112 NPI number — PACIFIC NORTHWEST UROGYNECOLOGY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC NORTHWEST UROGYNECOLOGY PLLC
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:
1205015112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98009-0128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-329-7897
Provider Business Mailing Address Fax Number:
360-925-2898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
903 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98223-1697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-329-7897
Provider Business Practice Location Address Fax Number:
360-925-2898
Provider Enumeration Date:
10/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SILVA
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
ANDRE
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
206-658-7652

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD00044925 , 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: 1205015112 . This is a "MEDICAID BILLING PROVIDER #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1205015112 . This is a "TYPE 2 (GROUP/ORGANIZATIONAL) NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2025944 . This is a "PROVIDER ONE # (LINKED TO TYPE 2 NPI)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0307100 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1861413965 . This is a "TYPE 1 (INDIVIDUAL) NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: G8917674 . This is a "MEDICARE PTAN FOR INDIVIDUAL (ARLINGTON, WA)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1861413965 . This is a "MEDICAID RENDERING PROVIDER #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8917673 . This is a "MEDICARE PTAN FOR GROUP (ARLINGTON, WA)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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