Provider Demographics
NPI:1114957875
Name:NORTHWEST SURGICAL GROUP PC
Entity Type:Organization
Organization Name:NORTHWEST SURGICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CLARENCE
Authorized Official - Last Name:WILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-754-1029
Mailing Address - Street 1:3920 CAPITOL MALL DR SW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8700
Mailing Address - Country:US
Mailing Address - Phone:360-754-1029
Mailing Address - Fax:390-754-7885
Practice Address - Street 1:3920 CAPITOL MALL DR SW
Practice Address - Street 2:SUITE 201
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8700
Practice Address - Country:US
Practice Address - Phone:360-754-1029
Practice Address - Fax:390-754-7885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601009261174400000X
WAMD00029497208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7105182Medicaid
WAAB21323Medicare ID - Type Unspecified
WA7105182Medicaid