Provider Demographics
NPI:1114962446
Name:RICHMOND PEDIATRIC CLINIC INC. P.S.
Entity Type:Organization
Organization Name:RICHMOND PEDIATRIC CLINIC INC. P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECTY/TREAS
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:ERNST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-546-2421
Mailing Address - Street 1:357 NW RICHMOND BEACH RD
Mailing Address - Street 2:RICHMOND PEDIATRICS
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177
Mailing Address - Country:US
Mailing Address - Phone:206-546-2421
Mailing Address - Fax:206-542-9028
Practice Address - Street 1:357 NW RICHMOND BEACH RD
Practice Address - Street 2:RICHMOND PEDIATRICS
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98177
Practice Address - Country:US
Practice Address - Phone:206-546-2421
Practice Address - Fax:206-542-9028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
WAMD00038513208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7039175Medicaid
WA8253270Medicaid
WAG8935065Medicare PIN
WA7039175Medicaid