Provider Demographics
NPI:1639531445
Name:SUMMIT DERMATOLOGY PS
Entity Type:Organization
Organization Name:SUMMIT DERMATOLOGY PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-754-4352
Mailing Address - Street 1:300 LILLY RD NE
Mailing Address - Street 2:UNIT A
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 LILLY RD NE
Practice Address - Street 2:UNIT A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5428
Practice Address - Country:US
Practice Address - Phone:360-754-4352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042827207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty