Provider Demographics
NPI:1003865072
Name:LONGVIEW ORTHOPEDIC ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:LONGVIEW ORTHOPEDIC ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:GRAGG
Authorized Official - Last Name:BLACKSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-501-3400
Mailing Address - Street 1:625 - 9TH AVE.
Mailing Address - Street 2:STE. 210
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2465
Mailing Address - Country:US
Mailing Address - Phone:360-501-3400
Mailing Address - Fax:360-423-6862
Practice Address - Street 1:625 - 9TH AVE.
Practice Address - Street 2:STE. 210
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2465
Practice Address - Country:US
Practice Address - Phone:360-501-3400
Practice Address - Fax:360-423-6862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269896Medicaid
WA5445810001OtherCIGNA DME
WADD4041OtherRAILROAD MEDICARE
WA0198037OtherLABOR & INDUSTRIES
WA7127632Medicaid
WA8854686Medicare ID - Type UnspecifiedGROUP PROVIDER NO
WADD4041OtherRAILROAD MEDICARE