Provider Demographics
NPI:1932652823
Name:PHYSICAL MEDICINE NORTHWEST
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE NORTHWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:E
Authorized Official - Last Name:FITZTHUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-967-6974
Mailing Address - Street 1:549 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3149
Mailing Address - Country:US
Mailing Address - Phone:425-967-6974
Mailing Address - Fax:425-967-5480
Practice Address - Street 1:549 MAIN ST
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3149
Practice Address - Country:US
Practice Address - Phone:425-967-6974
Practice Address - Fax:425-967-5480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 00038676261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF61171Medicare UPIN