Provider Demographics
NPI:1629194550
Name:PHILLIP A MEDINA MD INC PS
Entity Type:Organization
Organization Name:PHILLIP A MEDINA MD INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-226-1180
Mailing Address - Street 1:4361 TALBOT RD S STE 102
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6226
Mailing Address - Country:US
Mailing Address - Phone:425-226-1180
Mailing Address - Fax:425-235-0695
Practice Address - Street 1:4361 TALBOT RD S STE 102
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6226
Practice Address - Country:US
Practice Address - Phone:425-226-1180
Practice Address - Fax:425-235-0695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028329207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E74965Medicare UPIN