Provider Demographics
NPI:1013138536
Name:WESTERN WASHINGTON MEDICAL GROUP, INC, PS
Entity Type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP, INC, PS
Other - Org Name:DBA: GATEWAY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLINE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-374-5176
Mailing Address - Street 1:3726 BROADWAY SUITE 206
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3787
Mailing Address - Country:US
Mailing Address - Phone:425-374-5160
Mailing Address - Fax:425-374-5161
Practice Address - Street 1:3726 BROADWAY SUITE 206
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3787
Practice Address - Country:US
Practice Address - Phone:425-374-5160
Practice Address - Fax:425-374-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7139009Medicaid
WAG8865014Medicare PIN