Provider Demographics
NPI:1104971845
Name:GRAYS HARBOR PEDIATRICS, PLLC
Entity type:Organization
Organization Name:GRAYS HARBOR PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:C
Authorized Official - Last Name:MAGSALAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-533-7677
Mailing Address - Street 1:611 N F ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-2667
Mailing Address - Country:US
Mailing Address - Phone:360-533-7677
Mailing Address - Fax:360-533-0470
Practice Address - Street 1:611 N F ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-2667
Practice Address - Country:US
Practice Address - Phone:360-533-7677
Practice Address - Fax:360-533-0470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7131519Medicaid