Provider Demographics
NPI:1265750830
Name:ST. PAUL MEDICAL CLINIC, P.S.
Entity type:Organization
Organization Name:ST. PAUL MEDICAL CLINIC, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:206-240-0422
Mailing Address - Street 1:510 6TH AVE S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3877
Mailing Address - Country:US
Mailing Address - Phone:206-240-0422
Mailing Address - Fax:
Practice Address - Street 1:510 6TH AVE S
Practice Address - Street 2:101
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3877
Practice Address - Country:US
Practice Address - Phone:206-240-0422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60001377261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care