Provider Demographics
NPI:1154354660
Name:ST. JOHN'S EMERGENCY PHYSICIANS, INC., P.S.
Entity type:Organization
Organization Name:ST. JOHN'S EMERGENCY PHYSICIANS, INC., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:BEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-448-0587
Mailing Address - Street 1:PO BOX 101519
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91189-0009
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-414-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227368Medicaid
WA1028089Medicaid
WAGAB35435Medicare PIN