Provider Demographics
NPI:1083600480
Name:LOIS BRESAW MD INC PS
Entity Type:Organization
Organization Name:LOIS BRESAW MD INC PS
Other - Org Name:OLYMPIC GYNECOLOGY AND WOMEN'S CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRESAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-697-2199
Mailing Address - Street 1:20700 BOND RD NE BLDG B
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-9099
Mailing Address - Country:US
Mailing Address - Phone:360-697-2199
Mailing Address - Fax:360-779-5760
Practice Address - Street 1:20700 BOND RD NE BLDG B
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-9099
Practice Address - Country:US
Practice Address - Phone:360-697-2199
Practice Address - Fax:360-779-5760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024914174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7076888Medicaid
WA7076888Medicaid
WAE17388Medicare UPIN