Provider Demographics
NPI:1467407353
Name:SOUTH SOUND SURGERY, PLLC
Entity Type:Organization
Organization Name:SOUTH SOUND SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-394-0125
Mailing Address - Street 1:PO BOX 1409
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98071-1409
Mailing Address - Country:US
Mailing Address - Phone:253-394-0125
Mailing Address - Fax:
Practice Address - Street 1:101 2ND ST NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4902
Practice Address - Country:US
Practice Address - Phone:253-394-0125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH SOUND SURGERY, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-23
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046250208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7135429Medicaid
WAG8860410Medicare PIN