Provider Demographics
NPI:1215155619
Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-4041
Mailing Address - Street 1:12728 19TH AVE SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-6526
Mailing Address - Country:US
Mailing Address - Phone:425-252-1116
Mailing Address - Fax:425-252-1118
Practice Address - Street 1:12728 19TH AVE SE
Practice Address - Street 2:SUITE 300
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6526
Practice Address - Country:US
Practice Address - Phone:425-252-1116
Practice Address - Fax:425-252-1118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WASHINGTON MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601474013207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACE7385OtherRAILROAD MEDICARE
WA0037220OtherLABOR & INDUSTRY
WA7056948Medicaid
WA115100500Medicare PIN