Provider Demographics
NPI:1407940331
Name:CORLISS, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:CORLISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5814 GRAHAM AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-2728
Mailing Address - Country:US
Mailing Address - Phone:253-863-4474
Mailing Address - Fax:253-863-4062
Practice Address - Street 1:5814 GRAHAM AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-2728
Practice Address - Country:US
Practice Address - Phone:253-863-4474
Practice Address - Fax:253-863-4062
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-04-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00032451207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110202913OtherRAILROAD MEDICARE
WA1094093Medicaid
WA101904OtherDEPT OF LABOR AND INDUST
WA110202913OtherRAILROAD MEDICARE
WA1094093Medicaid