1912010984 NPI number — KITSAP GENERAL SURGERY PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912010984 NPI number — KITSAP GENERAL SURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KITSAP GENERAL SURGERY 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:
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:
1912010984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9927 MICKELBERRY RD NW
Provider Second Line Business Mailing Address:
SUITE 121
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-9195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-613-1335
Provider Business Mailing Address Fax Number:
360-613-1329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9927 MICKELBERRY RD NW
Provider Second Line Business Practice Location Address:
SUITE 121
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98383-9195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-613-1335
Provider Business Practice Location Address Fax Number:
360-613-1329
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHUN
Authorized Official First Name:
TY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIANPARTNER
Authorized Official Telephone Number:
360-613-1335

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7134984 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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