Provider Demographics
NPI:1194045542
Name:WESTERN WASHINGTON MEDICAL GROUP
Entity Type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-4041
Mailing Address - Street 1:1728 W MARINE VIEW DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2094
Mailing Address - Country:US
Mailing Address - Phone:425-259-4041
Mailing Address - Fax:
Practice Address - Street 1:1909 214TH ST SE
Practice Address - Street 2:SUITE 211
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-4412
Practice Address - Country:US
Practice Address - Phone:425-420-1655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207RG0100X174400000X
WA207RC0000X174400000X
WA207RE0101X174400000X
WA213E00000X174400000X
WA207Y00000X174400000X
WA291U00000X174400000X
WA207R00000X207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty