Provider Demographics
NPI:1205805264
Name:KITSAP INTERNAL MEDICINE ASSOCIATES, INC, P.S.
Entity type:Organization
Organization Name:KITSAP INTERNAL MEDICINE ASSOCIATES, INC, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:M
Authorized Official - Last Name:AXTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-377-8571
Mailing Address - Street 1:2601 CHERRY AVE
Mailing Address - Street 2:SUITE 315
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-4203
Mailing Address - Country:US
Mailing Address - Phone:360-377-8571
Mailing Address - Fax:360-792-1608
Practice Address - Street 1:2601 CHERRY AVE
Practice Address - Street 2:SUITE 315
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4203
Practice Address - Country:US
Practice Address - Phone:360-377-8571
Practice Address - Fax:360-792-1608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600150638173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000247500Medicare ID - Type Unspecified