Provider Demographics
NPI:1073684692
Name:SOUTH SOUND PEDIATRICS PLLC
Entity Type:Organization
Organization Name:SOUTH SOUND PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MURDOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-456-1600
Mailing Address - Street 1:3525 ENSIGN RD
Mailing Address - Street 2:SUITE K
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506
Mailing Address - Country:US
Mailing Address - Phone:360-456-1600
Mailing Address - Fax:360-456-3827
Practice Address - Street 1:3525 ENSIGN RD
Practice Address - Street 2:SUITE K
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-456-1600
Practice Address - Fax:360-456-3827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7036924Medicaid