1104971845 NPI number — GRAYS HARBOR PEDIATRICS, PLLC

Table of content: (NPI 1104971845)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104971845 NPI number — GRAYS HARBOR PEDIATRICS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAYS HARBOR PEDIATRICS, 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:
1104971845
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 N F ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98520-2667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-533-7677
Provider Business Mailing Address Fax Number:
360-533-0470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 N F ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98520-2667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-533-7677
Provider Business Practice Location Address Fax Number:
360-533-0470
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAGSALAY
Authorized Official First Name:
EDGARDO
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
360-533-7677

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7131519 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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