Provider Demographics
NPI:1659559409
Name:4TH STREET MEDICAL CARE PLLC
Entity Type:Organization
Organization Name:4TH STREET MEDICAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANTOSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-659-4141
Mailing Address - Street 1:1602 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-5014
Mailing Address - Country:US
Mailing Address - Phone:360-659-4141
Mailing Address - Fax:360-659-1712
Practice Address - Street 1:1602 4TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-5014
Practice Address - Country:US
Practice Address - Phone:360-659-4141
Practice Address - Fax:360-659-1712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602329907261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care