Provider Demographics
NPI:1801825641
Name:FRANCISCAN MEDICAL GROUP
Entity Type:Organization
Organization Name:FRANCISCAN MEDICAL GROUP
Other - Org Name:FRANCISCAN MEDICAL CLINIC-ENUMCLAW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFF
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-779-6101
Mailing Address - Street 1:3021 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2369
Mailing Address - Country:US
Mailing Address - Phone:360-825-6511
Mailing Address - Fax:
Practice Address - Street 1:3021 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2369
Practice Address - Country:US
Practice Address - Phone:360-825-6511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRANCISCAN MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7093776Medicaid
WA0126687OtherSTATE L&I
WA7131584Medicaid
WAAB07290Medicare ID - Type Unspecified
WA7093776Medicaid
WA7131584Medicaid