Provider Demographics
NPI:1104064641
Name:INTERNAL MEDICINE CLINIC LLC
Entity type:Organization
Organization Name:INTERNAL MEDICINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JASWANT
Authorized Official - Middle Name:G
Authorized Official - Last Name:VIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-833-1735
Mailing Address - Street 1:202 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-5015
Mailing Address - Country:US
Mailing Address - Phone:253-833-1735
Mailing Address - Fax:253-833-8515
Practice Address - Street 1:202 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-5015
Practice Address - Country:US
Practice Address - Phone:253-833-1735
Practice Address - Fax:253-833-8515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048708261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care