Provider Demographics
NPI:1457008971
Name:IMPACT PHYSICIAN GROUP, WASHINGTON LLC
Entity Type:Organization
Organization Name:IMPACT PHYSICIAN GROUP, WASHINGTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-967-5599
Mailing Address - Street 1:21 EASTBROOK BND STE 218
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1546
Mailing Address - Country:US
Mailing Address - Phone:678-967-5599
Mailing Address - Fax:
Practice Address - Street 1:2805 NE 129TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-3324
Practice Address - Country:US
Practice Address - Phone:360-356-1890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty