Basic Information
Provider Information | |||||||||
NPI: | 1912213372 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SKAGIT FAMILY HEALTH CLINIC LLC COWAN SETH P MBR | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOUNT VERNON BIRTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 916 S 3RD ST | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982734324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603369997 | ||||||||
FaxNumber: | 3603365655 | ||||||||
Practice Location | |||||||||
Address1: | 916 S 3RD ST | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982734324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603369997 | ||||||||
FaxNumber: | 3603365655 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2010 | ||||||||
LastUpdateDate: | 09/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANTONICH | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3603369997 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QB0400X | CBC.FS.60172666 | WA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Birthing |
ID Information
ID | Type | State | Issuer | Description | 2008959 | 05 | WA |   | MEDICAID |