Provider Demographics
NPI:1700090503
Name:ROBERT W CRAVEN MD PC
Entity Type:Organization
Organization Name:ROBERT W CRAVEN MD PC
Other - Org Name:THE SPECIALTY CLINIC INC. PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:CRAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-417-5189
Mailing Address - Street 1:315 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6217
Mailing Address - Country:US
Mailing Address - Phone:360-417-5189
Mailing Address - Fax:360-417-5190
Practice Address - Street 1:315 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6217
Practice Address - Country:US
Practice Address - Phone:360-417-5189
Practice Address - Fax:360-417-5190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029457174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7091903Medicaid
WAGAB05978Medicare PIN