Provider Demographics
NPI:1700117264
Name:KINGSTON LIBERTY BAY INTERNAL MEDICINE
Entity Type:Organization
Organization Name:KINGSTON LIBERTY BAY INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUECHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-297-6900
Mailing Address - Street 1:25995 BARBER CUT OFF RD NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-8456
Mailing Address - Country:US
Mailing Address - Phone:360-297-6900
Mailing Address - Fax:360-297-2034
Practice Address - Street 1:25995 BARBER CUT OFF RD NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-8456
Practice Address - Country:US
Practice Address - Phone:360-297-6900
Practice Address - Fax:360-297-2034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10000878207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty