Provider Demographics
NPI:1649476755
Name:ROBERT W. KUNKLE MD, INC PS
Entity type:Organization
Organization Name:ROBERT W. KUNKLE MD, INC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-514-5687
Mailing Address - Street 1:439 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:FOX ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98333-9715
Mailing Address - Country:US
Mailing Address - Phone:253-853-3100
Mailing Address - Fax:253-549-2367
Practice Address - Street 1:6712 KIMBALL DR
Practice Address - Street 2:STE 101
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1212
Practice Address - Country:US
Practice Address - Phone:253-853-3100
Practice Address - Fax:253-549-2367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028126174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1106467Medicaid
WAA51544Medicare UPIN
WA1106467Medicaid