Provider Demographics
NPI:1194045708
Name:SOUTH WHIDBEY PEDIATRICS
Entity Type:Organization
Organization Name:SOUTH WHIDBEY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-331-1314
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249
Mailing Address - Country:US
Mailing Address - Phone:360-331-1314
Mailing Address - Fax:
Practice Address - Street 1:1690 LAYTON RD
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:WA
Practice Address - Zip Code:98249-9456
Practice Address - Country:US
Practice Address - Phone:360-331-1314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020537208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7090517Medicaid