Provider Demographics
NPI:1699838540
Name:WEST OLYMPIA INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:WEST OLYMPIA INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-352-2909
Mailing Address - Street 1:110 DELPHI RD NW
Mailing Address - Street 2:SUIE 101
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-1778
Mailing Address - Country:US
Mailing Address - Phone:360-352-2909
Mailing Address - Fax:360-352-2909
Practice Address - Street 1:110 DELPHI RD NW
Practice Address - Street 2:SUIE 101
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1778
Practice Address - Country:US
Practice Address - Phone:360-352-2909
Practice Address - Fax:360-352-2909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028885207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1069160Medicaid
WAWE9115OtherREGENCE BLUE SHIELD
WAWE9115OtherREGENCE BLUE SHIELD
WA1069160Medicaid