Provider Demographics
NPI:1437411667
Name:VANCOUVER MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:VANCOUVER MEDICAL GROUP PLLC
Other - Org Name:NW PAIN GROUP PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WERNER
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKSFELD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-433-9580
Mailing Address - Street 1:16821 SE MCGILLIVRAY BLVD
Mailing Address - Street 2:STE 204
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-0499
Mailing Address - Country:US
Mailing Address - Phone:360-433-9580
Mailing Address - Fax:
Practice Address - Street 1:16821 SE MCGILLIVRAY BLVD
Practice Address - Street 2:STE 204
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-0499
Practice Address - Country:US
Practice Address - Phone:360-433-9580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60161096111N00000X
WA111N00000X
WA033991207R00000X
WAPA60069915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6696340001Medicare NSC
WAG8910929Medicare PIN