Provider Demographics
NPI:1376549618
Name:CEDAR MEDICAL SPECIALTIES
Entity Type:Organization
Organization Name:CEDAR MEDICAL SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-759-5555
Mailing Address - Street 1:2202 S CEDAR ST
Mailing Address - Street 2:STE 100
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2318
Mailing Address - Country:US
Mailing Address - Phone:253-759-5555
Mailing Address - Fax:253-830-5420
Practice Address - Street 1:2202 S CEDAR ST
Practice Address - Street 2:STE 100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2318
Practice Address - Country:US
Practice Address - Phone:253-759-5555
Practice Address - Fax:253-830-5420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAFX00057086261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7110224Medicaid
WAG93874Medicare UPIN
WAA08333Medicare UPIN
WAAB25808Medicare ID - Type Unspecified
WAA08310Medicare UPIN
WAG32923Medicare UPIN
WAG98151Medicare UPIN
WA7110224Medicaid
WAA08863Medicare UPIN
WAG29086Medicare UPIN
WAH18678Medicare UPIN
WAH20896Medicare UPIN