Provider Demographics
NPI:1912043720
Name:ISSAQUAH MEDICAL GROUP
Entity Type:Organization
Organization Name:ISSAQUAH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:HOURIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-291-9562
Mailing Address - Street 1:450 NW GILMAN BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2483
Mailing Address - Country:US
Mailing Address - Phone:425-391-0705
Mailing Address - Fax:425-391-9562
Practice Address - Street 1:450 NW GILMAN BLVD STE 201
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2483
Practice Address - Country:US
Practice Address - Phone:425-391-0705
Practice Address - Fax:425-391-9562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00000637207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAE20228Medicare UPIN