1376761775 NPI number — WESTERN WASHINGTON MEDICAL GROUP, INC PS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376761775 NPI number — WESTERN WASHINGTON MEDICAL GROUP, INC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN WASHINGTON MEDICAL GROUP, INC 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:
WESTERN WA MEDICAL GROUP DEPT OF ORTHOPEDICS
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:
1376761775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3726 BROADWAY
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98201-3787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-317-9119
Provider Business Mailing Address Fax Number:
425-317-9118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3726 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201-3788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-317-9119
Provider Business Practice Location Address Fax Number:
425-317-9118
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCGINNIS
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PM SYSTEM ADMINISTRATOR
Authorized Official Telephone Number:
425-740-4148

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  601474013 , 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: 0036257 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CQ2138 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7067648 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0728350005 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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