Provider Demographics
NPI:1225251390
Name:CONVENIENT PHYSICIANS SERVICES PS
Entity Type:Organization
Organization Name:CONVENIENT PHYSICIANS SERVICES PS
Other - Org Name:CONVENIENT HEALTHCARE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-425-5845
Mailing Address - Street 1:1052 DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2102
Mailing Address - Country:US
Mailing Address - Phone:360-425-5845
Mailing Address - Fax:360-577-9066
Practice Address - Street 1:1052 DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2102
Practice Address - Country:US
Practice Address - Phone:360-425-5845
Practice Address - Fax:360-577-9066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA060706OtherREGENCE BLUE CROSS -WA
WA40060OtherLABOR AND INDUSTRY
WA7048580Medicaid
WA7048580Medicaid