Provider Demographics
NPI:1598806770
Name:MILL CREEK FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:MILL CREEK FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-338-4000
Mailing Address - Street 1:1025 153RD ST SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-4051
Mailing Address - Country:US
Mailing Address - Phone:425-338-4000
Mailing Address - Fax:425-745-6158
Practice Address - Street 1:1025 153RD ST SE
Practice Address - Street 2:SUITE 200
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-4051
Practice Address - Country:US
Practice Address - Phone:425-338-4000
Practice Address - Fax:425-745-6158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7098643Medicaid
WA7098643Medicaid