Provider Demographics
NPI:1720498280
Name:RAINIER PEDIATRICS, INC
Entity Type:Organization
Organization Name:RAINIER PEDIATRICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-732-5508
Mailing Address - Street 1:12904 94TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-5538
Mailing Address - Country:US
Mailing Address - Phone:253-841-3999
Mailing Address - Fax:253-841-7311
Practice Address - Street 1:12904 94TH AVE E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5538
Practice Address - Country:US
Practice Address - Phone:253-841-3999
Practice Address - Fax:253-841-7311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000147262080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1069103Medicaid
WA601845065OtherUBI
2080A0000XOtherTAXONOMY CODE
WA1000303437OtherEHR NLR REGISTRATION NUMBER