1740425685 NPI number — FAIRHAVEN FAMILY MEDICINE PS

Table of content: (NPI 1740425685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740425685 NPI number — FAIRHAVEN FAMILY MEDICINE PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRHAVEN FAMILY MEDICINE PS
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:
1740425685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 468
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98233-0468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-755-0311
Provider Business Mailing Address Fax Number:
360-755-1272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1030 E FAIRHAVEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98233-2006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-755-0311
Provider Business Practice Location Address Fax Number:
360-755-1272
Provider Enumeration Date:
12/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ALDRICH
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
360-755-0311

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  MD00013642 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM1300X , with the licence number: MD00023548 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: S57930 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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