Provider Demographics
NPI:1548215544
Name:FRANCISCAN MEDICAL GROUP
Entity Type:Organization
Organization Name:FRANCISCAN MEDICAL GROUP
Other - Org Name:FMG-NEUROSURGERY NW - PUYALLUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFF
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-779-6101
Mailing Address - Street 1:1708 YAKIMA AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5307
Mailing Address - Country:US
Mailing Address - Phone:253-426-4420
Mailing Address - Fax:253-426-4383
Practice Address - Street 1:205 15TH AVE SW
Practice Address - Street 2:STE D
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7873
Practice Address - Country:US
Practice Address - Phone:253-426-4420
Practice Address - Fax:253-426-4383
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRANCISCAN MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0190124OtherSTATE L&I
WA7115728Medicaid
WA0190124OtherSTATE L&I
WAG8808773Medicare PIN