Provider Demographics
NPI:1790846509
Name:NORTHWEST UROLOGY CENTER PS
Entity Type:Organization
Organization Name:NORTHWEST UROLOGY CENTER PS
Other - Org Name:ROBERT O MODARELLI MD PS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MODARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-272-8441
Mailing Address - Street 1:1624 S I ST
Mailing Address - Street 2:STE 204
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5016
Mailing Address - Country:US
Mailing Address - Phone:253-272-8441
Mailing Address - Fax:253-272-8096
Practice Address - Street 1:1624 S I ST
Practice Address - Street 2:STE 204
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5016
Practice Address - Country:US
Practice Address - Phone:253-272-8441
Practice Address - Fax:253-272-8096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7077449Medicaid