Provider Demographics
NPI:1639261258
Name:SOUTH SOUND SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:SOUTH SOUND SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:FJ
Authorized Official - Last Name:TOLLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-280-6612
Mailing Address - Street 1:5130 PATTISON LAKE LN SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-6416
Mailing Address - Country:US
Mailing Address - Phone:360-280-6612
Mailing Address - Fax:
Practice Address - Street 1:3900 CAPITAL MALL DR SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8654
Practice Address - Country:US
Practice Address - Phone:360-754-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601814468208600000X
2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7085947Medicaid
WA115566OtherLABOR AND INDUSTRIES
WA7085947Medicaid