1407055742 NPI number — SAN JUAN HEALTHCARE PC

Table of content: (NPI 1407055742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407055742 NPI number — SAN JUAN HEALTHCARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN JUAN HEALTHCARE PC
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:
1407055742
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRIDAY HARBOR
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98250-1550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-378-1338
Provider Business Mailing Address Fax Number:
360-378-1830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
689 AIRPORT CENTER DR SUITE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRIDAY HARBOR
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-378-1338
Provider Business Practice Location Address Fax Number:
360-378-8130
Provider Enumeration Date:
07/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOSSOM
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
BURK
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-378-1338

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 612622200 . This is a "US NATL PARK SERVICE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8937841 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 602732862 . This is a "UBI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: J5122 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 50D0990556 . This is a "CLIA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 612622200 . This is a "US CUSTOMAS & BORDER PROTECTION" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7138829 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9451SA . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: POO425655DG2646 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0152516 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 748121 . This is a "GROUP HEALTH COOPERATIVE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "DSHS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7135981 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7990344 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 361929500 . This is a "PARKS NATL L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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