Provider Demographics
NPI:1134290182
Name:PORT TOWNSEND SURGICAL ASSOC
Entity Type:Organization
Organization Name:PORT TOWNSEND SURGICAL ASSOC
Other - Org Name:MADRONA SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:DO FACOS
Authorized Official - Phone:360-385-5444
Mailing Address - Street 1:1010 SHERIDAN STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368
Mailing Address - Country:US
Mailing Address - Phone:360-385-5444
Mailing Address - Fax:360-385-5352
Practice Address - Street 1:1010 SHERIDAN STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368
Practice Address - Country:US
Practice Address - Phone:360-385-5444
Practice Address - Fax:360-385-5352
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORT TOWNSEND SURGICAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-13
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7107303Medicaid
WA1107127Medicaid
WA1107127Medicaid
AB08976Medicare ID - Type Unspecified
WA7107303Medicaid