Provider Demographics
NPI:1417175811
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 NEPHROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HIPPA PRIVACY OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-4041
Mailing Address - Street 1:1330 ROCKEFELLER AVE STE 450
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1677
Mailing Address - Country:US
Mailing Address - Phone:425-258-6801
Mailing Address - Fax:425-258-1944
Practice Address - Street 1:1330 ROCKEFELLER AVE STE 450
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1677
Practice Address - Country:US
Practice Address - Phone:425-258-6801
Practice Address - Fax:425-258-1944
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
WA601474013207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0050081OtherLABOR & INDUSTRY
WACJ9333OtherRAILROAD MEDICARE
WA7057029Medicaid
WA115100400Medicare PIN