Provider Demographics
NPI:1275562928
Name:FRANCISCAN MEDICAL GROUP
Entity Type:Organization
Organization Name:FRANCISCAN MEDICAL GROUP
Other - Org Name:TACOMA SOUTH MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFF
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-779-6101
Mailing Address - Street 1:2111 S 90TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-1822
Mailing Address - Country:US
Mailing Address - Phone:253-539-9700
Mailing Address - Fax:
Practice Address - Street 1:2111 S 90TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-1822
Practice Address - Country:US
Practice Address - Phone:253-539-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRANCISCAN MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-02
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041631207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0126502OtherSTATE L&I
WA8926851OtherSTATE CRIME VICTIMS
WA7093792Medicaid
WAGAB07308Medicare PIN
WA8926851OtherSTATE CRIME VICTIMS
AB07308Medicare ID - Type Unspecified