Provider Demographics
NPI:1780906255
Name:EAGLE SWEEP INTEGRATIVE INTERNAL MEDICINE INCORPORATED
Entity type:Organization
Organization Name:EAGLE SWEEP INTEGRATIVE INTERNAL MEDICINE INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-627-8493
Mailing Address - Street 1:3036 PERRY AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-5349
Mailing Address - Country:US
Mailing Address - Phone:360-627-8493
Mailing Address - Fax:360-627-7920
Practice Address - Street 1:3036 PERRY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-5349
Practice Address - Country:US
Practice Address - Phone:360-627-8493
Practice Address - Fax:360-627-7920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030507207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8897408Medicare PIN