Basic Information
| Provider Information | |||||||||
| NPI: | 1942962121 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN WASHINGTON MEDICAL GROUP, INC PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1728 W MARINE VIEW DR STE 110 | ||||||||
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| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982012094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252594041 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 13TH ST | ||||||||
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| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252612000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2021 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | HOLSTEIN | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4252594041 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0801X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
No ID Information.