1396793709 NPI number — THE DOCTORS CLINIC A PROFESSIONAL CORPORATION

Table of content: (NPI 1396793709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396793709 NPI number — THE DOCTORS CLINIC A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE DOCTORS CLINIC A PROFESSIONAL CORPORATION
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:
THE DOCTORS CLINIC A PART OF FRANCISCAN MEDICAL GROUP
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:
1396793709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9621 RIDGETOP BLVD NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-8502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 S KITSAP BLVD
Provider Second Line Business Practice Location Address:
BLDG. 1, SUITE 250
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-3773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-782-3000
Provider Business Practice Location Address Fax Number:
360-782-3040
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BURGHART
Authorized Official First Name:
JAY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
360-782-3600

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 337018600 . This is a "OWCP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CU0247 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7053895 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50D0635293 . This is a "CLIA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8919256 . This is a "CRIME VICTIMS COMPENSATIO" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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