Provider Demographics
NPI:1649498049
Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT FINANCIAL SVCS
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-740-4142
Mailing Address - Street 1:1728 W MARINE VIEW DR STE 110
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2094
Mailing Address - Country:US
Mailing Address - Phone:425-317-8025
Mailing Address - Fax:425-317-9516
Practice Address - Street 1:4225 HOYT AVE STE D
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2351
Practice Address - Country:US
Practice Address - Phone:425-317-8025
Practice Address - Fax:425-317-9516
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WASHINGTOM MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-23
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601474013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0176782OtherLABOR & INDUSTRY
WACB3566OtherRAILROAD MEDICARE
WA7108012Medicaid
WAAB27169Medicare PIN