Provider Demographics
NPI:1104013556
Name:SOAP LAKE FAMILY MEDICINE
Entity Type:Organization
Organization Name:SOAP LAKE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BEARUP
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:509-246-0540
Mailing Address - Street 1:127 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOAP LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98851-0958
Mailing Address - Country:US
Mailing Address - Phone:509-246-0540
Mailing Address - Fax:509-246-0358
Practice Address - Street 1:127 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:SOAP LAKE
Practice Address - State:WA
Practice Address - Zip Code:98851-0958
Practice Address - Country:US
Practice Address - Phone:509-246-0540
Practice Address - Fax:509-246-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty