1417175811 NPI number — WESTERN WASHINGTON MEDICAL GROUP, INC PS

Table of content: (NPI 1417175811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417175811 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 NEPHROLOGY
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:
1417175811
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:
1330 ROCKEFELLER AVE STE 450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98201-1677
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-258-6801
Provider Business Mailing Address Fax Number:
425-258-1944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1330 ROCKEFELLER AVE STE 450
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201-1677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-258-6801
Provider Business Practice Location Address Fax Number:
425-258-1944
Provider Enumeration Date:
04/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCGINNIS
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
Authorized Official Title or Position:
HIPPA PRIVACY OFFICER
Authorized Official Telephone Number:
425-259-4041

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , 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: 0050081 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CJ9333 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7057029 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".