Provider Demographics
NPI:1952561805
Name:PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHINDER
Authorized Official - Middle Name:SINGH
Authorized Official - Last Name:BADYAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-661-5939
Mailing Address - Street 1:32124 1ST AVENUE S STE 100
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-661-5939
Mailing Address - Fax:253-661-5929
Practice Address - Street 1:32124 1ST AVE S STE 100
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5761
Practice Address - Country:US
Practice Address - Phone:253-661-5939
Practice Address - Fax:253-661-5929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031337305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7056443Medicaid