Provider Demographics
NPI:1255805628
Name:FRED THYSELL MD
Entity type:Organization
Organization Name:FRED THYSELL MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:JARL
Authorized Official - Last Name:THYSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-823-3861
Mailing Address - Street 1:PO BOX 8051
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-0051
Mailing Address - Country:US
Mailing Address - Phone:509-469-1903
Mailing Address - Fax:509-469-1905
Practice Address - Street 1:2807 W WASHINGTON AVE STE 117
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98903-1367
Practice Address - Country:US
Practice Address - Phone:509-469-1903
Practice Address - Fax:509-469-1905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1006757Medicaid