1003169434 NPI number — UROLOGY NORTHWEST, PS

Table of content: (NPI 1003169434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003169434 NPI number — UROLOGY NORTHWEST, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UROLOGY NORTHWEST, 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:
Provider Other Organization Name Type Code:
6
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:
1003169434
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6005 244TH ST SW
Provider Second Line Business Mailing Address:
111
Provider Business Mailing Address City Name:
MOUNTLAKE TERRACE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98043-5400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-275-5547
Provider Business Mailing Address Fax Number:
425-275-5593

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 TONGASS AVE
Provider Second Line Business Practice Location Address:
3RD FLOOR VISITING CLINIC
Provider Business Practice Location Address City Name:
KETCHIKAN
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99901-5746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-881-5319
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CHAPMAN
Authorized Official First Name:
CANDY
Authorized Official Middle Name:
SHALON
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
425-275-5547

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MPG0374 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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