Provider Demographics
NPI:1053641183
Name:MOUNT RAINIER UROLOGY, INC, PS
Entity Type:Organization
Organization Name:MOUNT RAINIER UROLOGY, INC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & SOLO PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:ZADINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-350-0281
Mailing Address - Street 1:703 LILLY RD NE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5191
Mailing Address - Country:US
Mailing Address - Phone:360-350-0281
Mailing Address - Fax:360-918-8280
Practice Address - Street 1:703 LILLY RD NE
Practice Address - Street 2:SUITE 106
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5191
Practice Address - Country:US
Practice Address - Phone:360-350-0281
Practice Address - Fax:360-918-8280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 60116602208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8888955Medicare PIN