1114106796 NPI number — PUGET SOUND SPECIALTY PHYSICIANS PLLC

Table of content: (NPI 1114106796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114106796 NPI number — PUGET SOUND SPECIALTY PHYSICIANS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUGET SOUND SPECIALTY PHYSICIANS 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:
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:
1114106796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2728 E MAIN AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98372-3198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-841-2006
Provider Business Mailing Address Fax Number:
253-840-6691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2005 NW SAMMAMISH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98027-8940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-631-0585
Provider Business Practice Location Address Fax Number:
253-631-0596
Provider Enumeration Date:
10/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BIERMAN
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
253-631-0585

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , 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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