1013135417 NPI number — WESTERN WASHINGTON MEDICAL GROUP

Table of content: (NPI 1013135417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013135417 NPI number — WESTERN WASHINGTON MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN WASHINGTON MEDICAL GROUP
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:
1013135417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 13TH ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-297-5500
Provider Business Mailing Address Fax Number:
425-297-5553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 13TH ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-297-5500
Provider Business Practice Location Address Fax Number:
425-297-5553
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VELDMAN
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
425-259-4041

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , 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: 0080464 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CH5134 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7056989 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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