Provider Demographics
NPI:1356486260
Name:FRANCISCAN MEDICAL GROUP
Entity Type:Organization
Organization Name:FRANCISCAN MEDICAL GROUP
Other - Org Name:FMG-DUPONT 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 1:1175 CENTER DR
Mailing Address - Street 2:#130
Mailing Address - City:DUPONT
Mailing Address - State:WA
Mailing Address - Zip Code:98327-7733
Mailing Address - Country:US
Mailing Address - Phone:253-964-5260
Mailing Address - Fax:253-964-5266
Practice Address - Street 1:1175 CENTER DR
Practice Address - Street 2:#130
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-7733
Practice Address - Country:US
Practice Address - Phone:253-539-9735
Practice Address - Fax:253-539-7981
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRANCISCAN MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0217715OtherSTATE L&I
WA7137136Medicaid
WA7136674Medicaid
WA7136674Medicaid
WA1326440029Medicare NSC
WA7137136Medicaid