Provider Demographics
NPI:1255677118
Name:SOUTH SOUND RADIOLOGY - LEWIS COUNTY
Entity Type:Organization
Organization Name:SOUTH SOUND RADIOLOGY - LEWIS COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DIRCKX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-493-4612
Mailing Address - Street 1:3417 ENSIGN RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5064
Mailing Address - Country:US
Mailing Address - Phone:360-493-4600
Mailing Address - Fax:360-493-4603
Practice Address - Street 1:914 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9027
Practice Address - Country:US
Practice Address - Phone:360-330-8508
Practice Address - Fax:360-330-8583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH SOUND RADIOLOGIST INC P S
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-21
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA311408OtherLABOR & INDUSTRIES
WAG8918611OtherMEDICARE GROUP PTAN