Provider Demographics
NPI:1508056052
Name:SUMAS CLINIC, INC. P.S.
Entity Type:Organization
Organization Name:SUMAS CLINIC, INC. P.S.
Other - Org Name:DBA SUMAS MEDICAL CLINIC, SUMAS CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:LEE BRIAN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-988-9404
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:112 COLUMBIA ST.
Mailing Address - City:SUMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98295-1010
Mailing Address - Country:US
Mailing Address - Phone:360-988-9404
Mailing Address - Fax:360-988-9409
Practice Address - Street 1:112 COLUMBIA ST.
Practice Address - Street 2:
Practice Address - City:SUMAS
Practice Address - State:WA
Practice Address - Zip Code:98295-1010
Practice Address - Country:US
Practice Address - Phone:360-988-9404
Practice Address - Fax:360-988-9409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7127285Medicaid
WA8294498Medicaid
WA7127285Medicaid
WA8294498Medicaid