Provider Demographics
NPI:1235204595
Name:TRI-CITY DERM MANAGEMENT INC.
Entity Type:Organization
Organization Name:TRI-CITY DERM MANAGEMENT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-783-7413
Mailing Address - Street 1:4911 W CANAL DR
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4911 W CANAL DR
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1408
Practice Address - Country:US
Practice Address - Phone:509-783-7413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00011357207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1098912Medicaid
WAA07071Medicare UPIN
WAG000304693Medicare PIN