Provider Demographics
NPI:1124203963
Name:PUGET SOUND SPECIALTY PHYSICIANS PLLC
Entity Type:Organization
Organization Name:PUGET SOUND SPECIALTY PHYSICIANS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:QUEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-841-2006
Mailing Address - Street 1:2728 E MAIN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3198
Mailing Address - Country:US
Mailing Address - Phone:253-841-2006
Mailing Address - Fax:253-840-6691
Practice Address - Street 1:2728 E MAIN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3198
Practice Address - Country:US
Practice Address - Phone:253-841-2006
Practice Address - Fax:253-840-6691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7109770Medicaid
WA4384630006Medicare NSC
WAGAB25234Medicare PIN
WA4384630004Medicare NSC
WAAB25245Medicare PIN
WA8855254Medicare PIN
WAAB25236Medicare PIN
WAAB25244Medicare PIN
WAAB37681Medicare PIN
WAAB25243Medicare PIN
WAAB25238Medicare PIN
WA8855255Medicare PIN
WA7109770Medicaid
WAAB37680Medicare PIN
WAGAB25239Medicare PIN
WA4384630003Medicare NSC