Provider Demographics
NPI:1225256720
Name:WESTERN WASHINGTON MEDICAL GROUP
Entity Type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP
Other - Org Name:WESTERN WASHINGTON MEDICAL GROUP DEPT OF SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-740-4148
Mailing Address - Street 1:3216 NORTON AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4290
Mailing Address - Country:US
Mailing Address - Phone:425-259-3181
Mailing Address - Fax:425-258-3179
Practice Address - Street 1:3216 NORTON AVE STE 202
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4290
Practice Address - Country:US
Practice Address - Phone:425-259-3181
Practice Address - Fax:425-258-3179
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WASHINGTON MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-23
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601474013208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACS8495OtherRAILROAD MEDICARE
WA0049980OtherLABOR & INDUSTRIES
WA7056997Medicaid
WAAB07563Medicare PIN