Provider Demographics
NPI:1568638575
Name:STARKWEATHER ORTHOPEDIC & SPORTS MEDICINE CLINIC
Entity Type:Organization
Organization Name:STARKWEATHER ORTHOPEDIC & SPORTS MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:J
Authorized Official - Last Name:STARKWEATHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-662-3838
Mailing Address - Street 1:304 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2107
Mailing Address - Country:US
Mailing Address - Phone:509-662-3838
Mailing Address - Fax:509-663-1108
Practice Address - Street 1:304 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2107
Practice Address - Country:US
Practice Address - Phone:509-662-3838
Practice Address - Fax:509-663-1108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016428174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1051986Medicaid
WAG000315411Medicare PIN
WA1051986Medicaid
WA0468280001Medicare NSC