Provider Demographics
NPI:1932327335
Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity Type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Other - Org Name:WESTERN WA MEDICAL GROUP, INC DEPT OF PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PATIENT FINANCIAL SVCS
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-740-4142
Mailing Address - Street 1:1728 W MARINE VIEW DR STE 110
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2094
Mailing Address - Country:US
Mailing Address - Phone:425-259-0855
Mailing Address - Fax:425-259-0856
Practice Address - Street 1:3802 BROADWAY STE B
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-5032
Practice Address - Country:US
Practice Address - Phone:425-259-0855
Practice Address - Fax:425-259-0856
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WASHINGTON MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-23
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601474013213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7119019Medicaid
WADA5528OtherRAILROAD MEDICARE
WA0114986OtherLABOR & INDUSTRIE
WAAB39045Medicare PIN
WA7119019Medicaid