Provider Demographics
NPI:1063435998
Name:PARKVIEW PEDIATRICS INC
Entity type:Organization
Organization Name:PARKVIEW PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:A DUDIK
Authorized Official - Last Name:BROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-766-9450
Mailing Address - Street 1:615 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-3800
Mailing Address - Country:US
Mailing Address - Phone:509-766-9450
Mailing Address - Fax:509-766-1954
Practice Address - Street 1:615 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-3800
Practice Address - Country:US
Practice Address - Phone:509-766-9450
Practice Address - Fax:509-766-1954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7590771261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7590771Medicaid
WA7590771Medicaid
WAG60590Medicare UPIN