Provider Demographics
NPI:1376761775
Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity Type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Other - Org Name:WESTERN WA MEDICAL GROUP DEPT OF ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PM SYSTEM ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCGINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-740-4148
Mailing Address - Street 1:3726 BROADWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3787
Mailing Address - Country:US
Mailing Address - Phone:425-317-9119
Mailing Address - Fax:425-317-9118
Practice Address - Street 1:3726 BROADWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3788
Practice Address - Country:US
Practice Address - Phone:425-317-9119
Practice Address - Fax:425-317-9118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WASHINGTON MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601474013207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0036257OtherLABOR & INDUSTRY
WACQ2138OtherRAILROAD MEDICARE
WA7067648Medicaid
0728350005OtherNPI
WA0728350005Medicare NSC
WACQ2138OtherRAILROAD MEDICARE