Provider Demographics
NPI:1104987734
Name:SOUTH SOUND INTERNAL MEDICINE PLLC
Entity type:Organization
Organization Name:SOUTH SOUND INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-491-1112
Mailing Address - Street 1:3425 ENSIGN RD NE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5425
Mailing Address - Country:US
Mailing Address - Phone:360-491-1112
Mailing Address - Fax:360-493-8160
Practice Address - Street 1:3425 ENSIGN RD NE
Practice Address - Street 2:SUITE 220
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5425
Practice Address - Country:US
Practice Address - Phone:360-491-1112
Practice Address - Fax:360-493-8160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAGAB20096171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0149442OtherLABOR & INDUSTRIES
WA7106826Medicaid
WA3911OtherCOUNTY
WA7106826Medicaid
WA0149442OtherLABOR & INDUSTRIES
WA0149442OtherLABOR & INDUSTRIES