Provider Demographics
NPI:1841200755
Name:EICKERMAN, MICHAEL SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:EICKERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19030 LENTON PL SE # 608
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1353
Mailing Address - Country:US
Mailing Address - Phone:360-794-1415
Mailing Address - Fax:
Practice Address - Street 1:14841 179TH AVE SE STE 140
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1127
Practice Address - Country:US
Practice Address - Phone:360-794-1415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA30108208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1103571Medicaid
WAGAB03384Medicare ID - Type Unspecified
WA1103571Medicaid