Provider Demographics
NPI:1194973628
Name:MARYS CORNER MEDICAL CLINIC INC PS
Entity type:Organization
Organization Name:MARYS CORNER MEDICAL CLINIC INC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:HOPE
Authorized Official - Last Name:INGLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-262-3966
Mailing Address - Street 1:4254 JACKSON HWY.
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532
Mailing Address - Country:US
Mailing Address - Phone:360-262-3966
Mailing Address - Fax:360-262-3967
Practice Address - Street 1:4254 JACKSON HWY
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532
Practice Address - Country:US
Practice Address - Phone:360-262-3966
Practice Address - Fax:360-262-3967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039760207Q00000X, 261QR1300X
WAOP00000823207Q00000X, 261QR1300X
WAAP30005675261QR1300X, 363LF0000X
WAPA0004588261QR1300X
WAPA10004588363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7132244Medicaid
WA7132764Medicaid
WA503898Medicare Oscar/Certification
WA7132244Medicaid