1922383207 NPI number — B MICHAEL SOUTHAM O D PC

Table of content: (NPI 1922383207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922383207 NPI number — B MICHAEL SOUTHAM O D PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
B MICHAEL SOUTHAM O D PC
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:
B. MICHAEL SOUTHAM, O.D., PC/FAMILY VISION CARE OF CENTRAL WASHINGTON
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:
1922383207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 54
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND COULEE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99133-0054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-633-0340
Provider Business Mailing Address Fax Number:
509-633-0161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 BURDIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND COULEE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99133-0054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-633-0340
Provider Business Practice Location Address Fax Number:
509-633-0161
Provider Enumeration Date:
10/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SOUTHAM
Authorized Official First Name:
BRANT
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OPTOMETRIST/OWNER
Authorized Official Telephone Number:
509-633-0340

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  60235215 , 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)





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