Provider Demographics
NPI:1548210719
Name:PEDIATRIC CRITICAL CARE ASSOCIATES PS
Entity Type:Organization
Organization Name:PEDIATRIC CRITICAL CARE ASSOCIATES PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETERY TRESURER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-474-5233
Mailing Address - Street 1:PO BOX 84301
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-5601
Mailing Address - Country:US
Mailing Address - Phone:509-926-1770
Mailing Address - Fax:509-228-9542
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-474-7461
Practice Address - Fax:509-474-5233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7055130Medicaid
WA7108640Medicaid