1770791816 NPI number — FAMILY PHYSICIANS GENERAL CLINIC

Table of content: (NPI 1770791816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770791816 NPI number — FAMILY PHYSICIANS GENERAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY PHYSICIANS GENERAL CLINIC
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:
FAMILY PHYSICIANS GC
Provider Other Organization Name Type Code:
5
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:
1770791816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12459 AMBAUM BLVD SW STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURIEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98146-2660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-444-6533
Provider Business Mailing Address Fax Number:
206-439-0421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12459 AMBAUM BLVD SW STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURIEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98146-2660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-444-6533
Provider Business Practice Location Address Fax Number:
206-439-0421
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SPALEK
Authorized Official First Name:
NINA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
206-444-6533

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  MD00021620 , 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: 50D0944376 . This is a "CLIA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: SP8107 . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 122873 . This is a "L AND I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7113020 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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