Provider Demographics
NPI:1154457281
Name:MV-ANESTHESIA PS
Entity Type:Organization
Organization Name:MV-ANESTHESIA PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRILYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-434-3009
Mailing Address - Street 1:PO BOX 11810
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-5810
Mailing Address - Country:US
Mailing Address - Phone:360-434-3009
Mailing Address - Fax:360-895-5380
Practice Address - Street 1:110 N 30TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-3668
Practice Address - Country:US
Practice Address - Phone:360-434-3009
Practice Address - Fax:360-895-5380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033163207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0196474OtherL&I
WA1577DOOtherREGENCE
WAF36952Medicare UPIN
WA0196474OtherL&I
WA8856797Medicare ID - Type UnspecifiedMEDICARE