Provider Demographics
NPI:1790824332
Name:ROBERT BRUCE WORTH MD INC PS
Entity Type:Organization
Organization Name:ROBERT BRUCE WORTH MD INC PS
Other - Org Name:R. BRUCE WORTH MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-533-6063
Mailing Address - Street 1:1020 ANDERSON DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-1055
Mailing Address - Country:US
Mailing Address - Phone:360-533-6063
Mailing Address - Fax:360-533-2204
Practice Address - Street 1:1020 ANDERSON DR
Practice Address - Street 2:SUITE 203
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-1055
Practice Address - Country:US
Practice Address - Phone:360-533-6063
Practice Address - Fax:360-533-2204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018292207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1928209Medicaid
A08247Medicare UPIN