1497737308 NPI number — EDWARD S CARMICK JR MD

Table of content: (NPI 1497737308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497737308 NPI number — EDWARD S CARMICK JR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD S CARMICK JR MD
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:
1497737308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2528 WHEATON WAY
Provider Second Line Business Mailing Address:
# 204
Provider Business Mailing Address City Name:
BREMERTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98310-3305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-478-0522
Provider Business Mailing Address Fax Number:
360-479-0225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2528 WHEATON WAY
Provider Second Line Business Practice Location Address:
# 204
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98310-3305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-478-0522
Provider Business Practice Location Address Fax Number:
360-479-0225
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARMICK
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MEDICAL DOCTOR
Authorized Official Telephone Number:
360-478-0522

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  00010274 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207NS0135X , with the licence number: 00010274 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1092519 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81892 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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