Basic Information
| Provider Information | |||||||||
| NPI: | 1861599573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OBSTETRIX MEDICAL GROUP OF WASHINGTON INC PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 CONCORD TER | ||||||||
| Address2: | |||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543840175 | ||||||||
| FaxNumber: | 9548511948 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 THE CITY DR S | ||||||||
| Address2: | SUITE 4000 | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004636628 | ||||||||
| FaxNumber: | 7147400326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 07/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9543840175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 207PP0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2080N0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207VM0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | MDG47WA | 05 | AK | MEDICAID | 7107162 | 05 | WA | MEDICAID | MDG46WA | 05 | AK | MEDICAID | 7099179 | 05 | WA | MEDICAID | 807704300 | 05 | ID | MEDICAID |