Provider Demographics
NPI:1336129154
Name:SIDNEY F WHALEY JR
Entity Type:Organization
Organization Name:SIDNEY F WHALEY JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:F
Authorized Official - Last Name:WHALEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:253-383-1529
Mailing Address - Street 1:314 MLK JR WY #210
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4271
Mailing Address - Country:US
Mailing Address - Phone:253-383-1529
Mailing Address - Fax:253-593-4344
Practice Address - Street 1:314 MLK JR WY #210
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4271
Practice Address - Country:US
Practice Address - Phone:253-383-1529
Practice Address - Fax:253-593-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA10945207N00000X, 207ND0101X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1930007Medicaid
WH4111OtherREGENCE
A08650Medicare UPIN