Provider Demographics
NPI:1982994356
Name:MEMORIAL PHYSICIANS, PLLC
Entity Type:Organization
Organization Name:MEMORIAL PHYSICIANS, PLLC
Other - Org Name:LAKEVIEW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-248-7849
Mailing Address - Street 1:3800 SUMMITVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2715
Mailing Address - Country:US
Mailing Address - Phone:509-574-6000
Mailing Address - Fax:509-225-2714
Practice Address - Street 1:1470 N 16TH AVE
Practice Address - Street 2:SUITE D
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-1381
Practice Address - Country:US
Practice Address - Phone:509-574-6000
Practice Address - Fax:509-225-2714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602902835261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8890668OtherMEDICARE
WA6366730002Medicare NSC