1649383613 NPI number — PETER THOMAS PHD PERSONAL COPORATION

Table of content: (NPI 1649383613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649383613 NPI number — PETER THOMAS PHD PERSONAL COPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETER THOMAS PHD PERSONAL COPORATION
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:
PETER THOMAS, PHD
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:
1649383613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19018 CORLISS AVE N STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHORELINE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98133-4146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-356-8724
Provider Business Mailing Address Fax Number:
206-417-2841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19018 CORLISS AVE N STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHORELINE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98133-4146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-356-8724
Provider Business Practice Location Address Fax Number:
206-417-2841
Provider Enumeration Date:
08/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
PETER
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
206-356-8724

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1172 , 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: 8912335 . This is a "CRIME VICTIMS COMP PROV#" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 78567 . This is a "LABOR & INDUSTRIES PROV#" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: AETNA . This is a "5113341" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".