Provider Demographics
NPI:1760577480
Name:THOMAS B VADER MD PS
Entity Type:Organization
Organization Name:THOMAS B VADER MD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:VADER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-678-4071
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-0129
Mailing Address - Country:US
Mailing Address - Phone:360-678-4071
Mailing Address - Fax:360-678-6014
Practice Address - Street 1:101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239-3413
Practice Address - Country:US
Practice Address - Phone:360-678-7608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015541174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty