Provider Demographics
NPI:1649368341
Name:SURGERY CENTER ENUMCLAW
Entity type:Organization
Organization Name:SURGERY CENTER ENUMCLAW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-825-7500
Mailing Address - Street 1:2820 GRIFFIN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2373
Mailing Address - Country:US
Mailing Address - Phone:360-802-5231
Mailing Address - Fax:360-802-5236
Practice Address - Street 1:2820 GRIFFIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2373
Practice Address - Country:US
Practice Address - Phone:360-802-5231
Practice Address - Fax:360-802-5236
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUGET SOUND SPECIALTY PHYSICIANS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAFX00057007261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB23305Medicare PIN