Provider Demographics
NPI:1700902368
Name:NORTHWEST CARDIOVASCULAR
Entity Type:Organization
Organization Name:NORTHWEST CARDIOVASCULAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MEDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-572-8777
Mailing Address - Street 1:1812 S J ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4964
Mailing Address - Country:US
Mailing Address - Phone:253-572-8777
Mailing Address - Fax:253-572-8835
Practice Address - Street 1:1812 S J ST
Practice Address - Street 2:SUITE 210
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4964
Practice Address - Country:US
Practice Address - Phone:253-572-8777
Practice Address - Fax:253-572-8835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7129372Medicaid
WA7129372Medicaid