1003841958 NPI number — DR. RICHARD SCOTT ELLOWAY M.D.

Table of content: DR. RICHARD SCOTT ELLOWAY M.D. (NPI 1003841958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003841958 NPI number — DR. RICHARD SCOTT ELLOWAY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLOWAY
Provider First Name:
RICHARD
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLOWAY
Provider Other First Name:
RICHARD
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1003841958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 MARVIN ROAD, NE
Provider Second Line Business Mailing Address:
SUITE 307 PMB 266
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98516-5709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-491-5055
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 S. SCHEUBER ROAD
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98531-8877
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-330-8808
Provider Business Practice Location Address Fax Number:
360-330-8816
Provider Enumeration Date:
07/11/2006

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: 207RG0100X , with the licence number:  MD00029202 , 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: 911639821 . This is a "TAX ID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 100005752 . This is a "RR MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 58585 . This is a "L&I WORKERS COMP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: D20530 . This is a "PACC" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: EL5942 . This is a "BL CROSS BL SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1086933 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 333154001 . This is a "GROUP HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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