1508056052 NPI number — SUMAS CLINIC, INC. P.S.

Table of content: (NPI 1508056052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508056052 NPI number — SUMAS CLINIC, INC. P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMAS CLINIC, INC. P.S.
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:
1508056052
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1010
Provider Second Line Business Mailing Address:
112 COLUMBIA ST.
Provider Business Mailing Address City Name:
SUMAS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98295-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-988-9404
Provider Business Mailing Address Fax Number:
360-988-9409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 COLUMBIA ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMAS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98295-1010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-988-9404
Provider Business Practice Location Address Fax Number:
360-988-9409
Provider Enumeration Date:
07/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
LEE BRIAN
Authorized Official Title or Position:
PHYSICIAN/PRESIDENT
Authorized Official Telephone Number:
360-988-9404

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD00039892 , 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: 7127285 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8294498 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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