Provider Demographics
NPI:1104010305
Name:FRANCISCAN MEDICAL GROUP
Entity Type:Organization
Organization Name:FRANCISCAN MEDICAL GROUP
Other - Org Name:LAKES FAMILY MEDICINE-LAKEWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFF
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-779-6101
Mailing Address - Street 1:5202 100TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3892
Mailing Address - Country:US
Mailing Address - Phone:253-588-3670
Mailing Address - Fax:253-588-3703
Practice Address - Street 1:5202 100TH ST SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3892
Practice Address - Country:US
Practice Address - Phone:253-588-3670
Practice Address - Fax:253-588-3703
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRANCISCAN MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-30
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0224336OtherSTATE L&I
WA7139157Medicaid
WAGAB07308Medicare PIN
WAAB07308Medicare PIN