Provider Demographics
NPI:1467482679
Name:NORTHWEST SURGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:NORTHWEST SURGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE/BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAHLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:360-426-4142
Mailing Address - Street 1:1710 N 13TH LOOP RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2166
Mailing Address - Country:US
Mailing Address - Phone:360-426-4142
Mailing Address - Fax:360-427-5772
Practice Address - Street 1:1710 N 13TH LOOP RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2166
Practice Address - Country:US
Practice Address - Phone:360-426-4142
Practice Address - Fax:360-427-5772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045973208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8860455Medicare PIN
WAI12358Medicare UPIN