Provider Demographics
NPI:1093723439
Name:FRANCISCAN MEDICAL GROUP
Entity Type:Organization
Organization Name:FRANCISCAN MEDICAL GROUP
Other - Org Name:THE LAKEWOOD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFF
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-779-6101
Mailing Address - Street 1:11311 BRIDGEPORT WAY SW
Mailing Address - Street 2:STE 100
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3071
Mailing Address - Country:US
Mailing Address - Phone:253-581-6688
Mailing Address - Fax:253-512-2894
Practice Address - Street 1:11311 BRIDGEPORT WAY SW
Practice Address - Street 2:STE 100
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3071
Practice Address - Country:US
Practice Address - Phone:253-581-6688
Practice Address - Fax:253-512-2894
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRANCISCAN MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-03
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0193323OtherSTATE L&I
WA7125057Medicaid
WA7130685Medicaid
WA7125057Medicaid
WA8850499Medicare ID - Type Unspecified
WAG8850499Medicare PIN