Provider Demographics
NPI:1528034030
Name:ORTHOPEDICS NORTHWEST PLLC
Entity Type:Organization
Organization Name:ORTHOPEDICS NORTHWEST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:STILLWAGGON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-834-6200
Mailing Address - Street 1:PO BOX 2309
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98907-2309
Mailing Address - Country:US
Mailing Address - Phone:509-454-8888
Mailing Address - Fax:509-453-0061
Practice Address - Street 1:111 S 11TH AVE STE 320
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3273
Practice Address - Country:US
Practice Address - Phone:509-454-8888
Practice Address - Fax:509-453-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602044113207X00000X
WA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1012469Medicaid
WA7106909Medicaid
WAGAB20135Medicare PIN