Provider Demographics
NPI:1760529374
Name:CREEKSIDE MEDICAL, P.S.
Entity Type:Organization
Organization Name:CREEKSIDE MEDICAL, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-566-9355
Mailing Address - Street 1:900 NE 139TH ST
Mailing Address - Street 2:STE 202
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-2513
Mailing Address - Country:US
Mailing Address - Phone:360-566-9355
Mailing Address - Fax:360-816-1327
Practice Address - Street 1:900 NE 139TH ST
Practice Address - Street 2:STE 202
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2513
Practice Address - Country:US
Practice Address - Phone:360-566-9355
Practice Address - Fax:360-816-1327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207R00000X, 208000000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1760529374Medicare PIN