Provider Demographics
NPI:1194919829
Name:PODIATRIC PHYSICIANS AND SURGEOANS PS
Entity type:Organization
Organization Name:PODIATRIC PHYSICIANS AND SURGEOANS PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KRIVOSHA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:206-447-0302
Mailing Address - Street 1:1101 MADISON ST
Mailing Address - Street 2:SUITE 1120
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3558
Mailing Address - Country:US
Mailing Address - Phone:206-447-0302
Mailing Address - Fax:206-681-5951
Practice Address - Street 1:1101 MADISON ST
Practice Address - Street 2:SUITE 1120
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1306
Practice Address - Country:US
Practice Address - Phone:206-447-0302
Practice Address - Fax:206-682-5951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPOOOO177213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1010701Medicaid
WV1086360001Medicare NSC
WAT01677Medicare UPIN
WAG000109840Medicare PIN