Provider Demographics
NPI:1700853983
Name:CASCADE INTERNAL MEDICINE PS
Entity Type:Organization
Organization Name:CASCADE INTERNAL MEDICINE PS
Other - Org Name:JOHN DANIEL WANWIG MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:WANWIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-272-3031
Mailing Address - Street 1:1901 SO UNION
Mailing Address - Street 2:ALLENMORE MEDICAL CENTER STE A305
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405
Mailing Address - Country:US
Mailing Address - Phone:253-272-3031
Mailing Address - Fax:253-272-9449
Practice Address - Street 1:1901 SO UNION
Practice Address - Street 2:ALLENMORE MEDICAL CENTER STE A305
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-272-3031
Practice Address - Fax:253-272-9449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA125822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1047786Medicaid
1300029OtherMEDICAID MEDICAL
WA21793OtherLABOR & INDUSTRIES
8914379OtherCRIME VICTIMS
WA7229OtherREGENCE
WA1047786Medicaid