1861577223 NPI number — ELLENDEE PEPPER MD

Table of content: ELLENDEE PEPPER MD (NPI 1861577223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861577223 NPI number — ELLENDEE PEPPER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEPPER
Provider First Name:
ELLENDEE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1861577223
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 34876
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-1876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-228-3440
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
660 SW 39TH ST
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98057-4912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-793-4700
Provider Business Practice Location Address Fax Number:
425-656-4046
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  MD00022801 , 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: 070011908 . This is a "RR MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1008770 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0123182 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: PE0386 . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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