Provider Demographics
NPI:1811015399
Name:SURGICAL WEIGHT LOSS CLINIC PLLC
Entity Type:Organization
Organization Name:SURGICAL WEIGHT LOSS CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-472-9850
Mailing Address - Street 1:3716 PACIFIC AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-7836
Mailing Address - Country:US
Mailing Address - Phone:253-472-9850
Mailing Address - Fax:
Practice Address - Street 1:3716 PACIFIC AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7836
Practice Address - Country:US
Practice Address - Phone:253-472-9850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0002094261QM2500X
WAMD00005293261QM2500X
WA261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1306919725OtherNPI FOR EARL ROSS FOX
WA1942363353OtherNPI FOR SAMUEL ROSS FOX
WA1016468OtherDSHS FOR EARL ROSS FOX
WA8178618OtherDSHS FOR SAMUEL ROSS FOX
WA7124175Medicaid
WA1016468OtherDSHS FOR EARL ROSS FOX
WA1306919725OtherNPI FOR EARL ROSS FOX
WAA04490Medicare UPIN