Provider Demographics
NPI:1003851338
Name:WHIDBEY ISLAND INTERNAL MEDICINE
Entity Type:Organization
Organization Name:WHIDBEY ISLAND INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:WHITNEY
Authorized Official - Last Name:ROOF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-678-4440
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-9556
Mailing Address - Country:US
Mailing Address - Phone:360-678-4440
Mailing Address - Fax:360-678-9244
Practice Address - Street 1:77 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239-9556
Practice Address - Country:US
Practice Address - Phone:360-678-4440
Practice Address - Fax:360-678-9244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7094352Medicaid
WAGAB06480Medicare ID - Type Unspecified