1235282443 NPI number — PACIFIC NORTHWEST ANESTHESIA SERVICES, INC., P.C.

Table of content: (NPI 1235282443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235282443 NPI number — PACIFIC NORTHWEST ANESTHESIA SERVICES, INC., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC NORTHWEST ANESTHESIA SERVICES, INC., P.C.
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:
1235282443
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 455
Provider Second Line Business Mailing Address:
PO BOX 455
Provider Business Mailing Address City Name:
HANSVILLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98340-0455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-908-2457
Provider Business Mailing Address Fax Number:
360-638-0058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41487 NE FOULWEATHER BLUFF ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANSVILLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98340-0455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-908-2457
Provider Business Practice Location Address Fax Number:
360-638-0058
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HERZOG
Authorized Official First Name:
TODD
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-908-2457

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  AP30002036 , 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: DG0886 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9636366 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0137504 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: REGENCE BLUE SHIELD . This is a "HE2316" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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