N.W. PEDIATRIC CENTER INC PS

Provider Demographics

• NPI: 1518034180
• Name: N.W. PEDIATRIC CENTER INC PS
• Entity Type: Organization
• Organization Name: N.W. PEDIATRIC CENTER INC PS
• Other - Org Name: NORTHWEST PEDIATRIC CENTER
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: PRACTICE MANAGER
• Authorized Official - First Name: LISA
• Authorized Official - Middle Name: GAIL
• Authorized Official - Last Name: MCKAY
• Authorized Official - Phone: 360-736-6778
• Mailing Address - Street 1: 1911 COOKS HILL RD
• Mailing Address - City: CENTRALIA
• Mailing Address - State: WA
• Mailing Address - Zip Code: 98531-9073
• Mailing Address - Country: US
• Mailing Address - Phone: 360-736-6778
• Mailing Address - Fax: 360-736-6552
• Practice Address - Street 1: 1911 COOKS HILL RD
• Practice Address - City: CENTRALIA
• Practice Address - State: WA
• Practice Address - Zip Code: 98531-9073
• Practice Address - Country: US
• Practice Address - Phone: 360-736-6778
• Practice Address - Fax: 360-736-6552
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: N.W. PEDIATRIC CENTER INC PS
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2006-11-29
• Last Update Date: 2009-06-11

Provider Licenses

State	License ID	Taxonomies
WA	MD00029916	208000000X
WA	MD00038226	208000000X
WA	MD00028578	208000000X
WA	MD00027525	208000000X
WA	MD00032554	208000000X
WA	MD00043677	208000000X
WA	MD00039351	2084P0804X
WA	AP30006273	363LP0200X
WA	AP30007039	363LP0200X
WA	AP60086265	363LP0200X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	208000000X	Allopathic & Osteopathic Physicians	Pediatrics		Group - Single Specialty
No	2084P0804X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Child & Adolescent Psychiatry	Group - Single Specialty
No	363LP0200X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Pediatrics	Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
WA	1058825	Medicaid
WA	218107	Other	JC PROVIDENCE HEALTH PLAN
WA	2914LO	Other	DR LO REGENCE
WA	9116SM	Other	DANA SMITH, ARNP REGENCE
WA	1194SM	Other	DANA SMITH, ARNP REGENCE
WA	2914CA	Other	JENNIFER CASERTA, MD REGE
WA	2914SM	Other	DANA SMITH, ARNP REGENCE
WA	2915CA	Other	JENNIFER CASERTA, MD REGE
WA	8024LO	Other	DR LO REGENCE
WA	9116CA	Other	JENNIFER CASETA, MD REGEN
WA	1914LO	Other	DR. LO REGENCE
WA	8173882	Medicaid
WA	212864	Other	DANA SMITH, ARNP PROVIDEN
WA	230532008	Other	JC GROUP HEALTH
WA	7057375	Medicaid
WA	8141947	Medicaid
WA	1072958	Medicaid
WA	8251324	Medicaid
WA	8398356	Medicaid
WA	9636994	Medicaid