1871508564 NPI number — CANCER INSTITUTES OF WASHINGTON, PLLC

Table of content: (NPI 1871508564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871508564 NPI number — CANCER INSTITUTES OF WASHINGTON, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANCER INSTITUTES OF WASHINGTON, PLLC
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:
WASHINGTON HEMATOLOGY ONCOLOGY
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:
1871508564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 996
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYDEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83835-0996
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-664-4026
Provider Business Mailing Address Fax Number:
208-664-4840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3911 CASTLEVALE RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98902-7807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-454-9499
Provider Business Practice Location Address Fax Number:
509-457-4994
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRADY
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PHYSICIAN / OWNER
Authorized Official Telephone Number:
509-454-9499

Provider Taxonomy Codes

  • Taxonomy code: 207RX0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: MD00044836 , 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: 7115017 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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