Provider Demographics
NPI:1285018432
Name:SOUTH SOUND MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:SOUTH SOUND MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN FLEET-GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-556-8465
Mailing Address - Street 1:10116 COACHMAN LN SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-9731
Mailing Address - Country:US
Mailing Address - Phone:360-556-8465
Mailing Address - Fax:
Practice Address - Street 1:10116 COACHMAN LN SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-9731
Practice Address - Country:US
Practice Address - Phone:360-556-8465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60162757207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1679736318OtherNPI
WA1679736318Medicaid
WA1679736318OtherNPI