Provider Demographics
NPI:1629024740
Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity Type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Other - Org Name:WESTERN WASHINGTON MEDICAL GROUP DEPARTMENT OF LABORATORY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCGINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-4041
Mailing Address - Street 1:1728 W MARINE VIEW DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2094
Mailing Address - Country:US
Mailing Address - Phone:425-740-4177
Mailing Address - Fax:425-252-6642
Practice Address - Street 1:4301 HOYT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2316
Practice Address - Country:US
Practice Address - Phone:425-257-9997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WASHINGTON MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00162700OtherRR MEDICARE
WA0188172OtherLABOR AND INDUSTRY
WA7124795Medicaid
WA7124795Medicaid