Provider Demographics
NPI:1043404163
Name:ROBERT QUACKENBUSH MD PLLC
Entity Type:Organization
Organization Name:ROBERT QUACKENBUSH MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:QUACKENBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-525-2220
Mailing Address - Street 1:PO BOX 2102
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0102
Mailing Address - Country:US
Mailing Address - Phone:509-525-2220
Mailing Address - Fax:509-525-4878
Practice Address - Street 1:40L W POPLAR ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-525-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039975174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADA4111OtherRRMC
ORR121093Medicare PIN
WAGAB39429Medicare PIN
WADA4111OtherRRMC