Basic Information
| Provider Information | |||||||||
| NPI: | 1225054141 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PHYSICIANS GROUP PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 SE STONE MILL DR | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986843545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607358100 | ||||||||
| FaxNumber: | 3607353400 | ||||||||
| Practice Location | |||||||||
| Address1: | 16811 SE MCGILLIVRAY BLVD | ||||||||
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| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986830400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607358100 | ||||||||
| FaxNumber: | 3607353400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | LITVIN | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3607358100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7984800 | 05 | WA | MEDICAID |