1760469985 NPI number — JOHN G CARROUGHER MD

Table of content: JOHN G CARROUGHER MD (NPI 1760469985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760469985 NPI number — JOHN G CARROUGHER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROUGHER
Provider First Name:
JOHN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1760469985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1112 6TH AVE
Provider Second Line Business Mailing Address:
200
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-4040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-272-8664
Provider Business Mailing Address Fax Number:
253-404-1352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1112 6TH AVE
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-4040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-272-8664
Provider Business Practice Location Address Fax Number:
253-404-1352
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  MD00025419 , 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: CA3856 . This is a "REGENCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 111878 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8205353 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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