Provider Demographics
NPI:1013135417
Name:WESTERN WASHINGTON MEDICAL GROUP
Entity Type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP
Other - Org Name:WESTERN WA MEDICAL GROUP DEPT OF HEMATOLOGY ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:VELDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-4041
Mailing Address - Street 1:1717 13TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201
Mailing Address - Country:US
Mailing Address - Phone:425-297-5500
Mailing Address - Fax:425-297-5553
Practice Address - Street 1:1717 13TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201
Practice Address - Country:US
Practice Address - Phone:425-297-5500
Practice Address - Fax:425-297-5553
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:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0080464OtherLABOR & INDUSTRY
WACH5134OtherRAILROAD MEDICARE
WA7056989Medicaid