1649498049 NPI number — WESTERN WASHINGTON MEDICAL GROUP, INC PS

Table of content: (NPI 1649498049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649498049 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 PRIMARY CARE
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:
1649498049
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1728 W MARINE VIEW DR STE 110
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:
98201-2094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-317-8025
Provider Business Mailing Address Fax Number:
425-317-9516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4225 HOYT AVE STE D
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:
98203-2351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-317-8025
Provider Business Practice Location Address Fax Number:
425-317-9516
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EDENS
Authorized Official First Name:
AMELIA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PATIENT FINANCIAL SVCS
Authorized Official Telephone Number:
425-740-4142

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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: 0176782 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CB3566 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7108012 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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