Provider Demographics
NPI:1285795815
Name:INDEPENDENT ANESTHESIOLOGISTS OF KITSAP CO
Entity type:Organization
Organization Name:INDEPENDENT ANESTHESIOLOGISTS OF KITSAP CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:PARK
Authorized Official - Last Name:LEAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-479-0809
Mailing Address - Street 1:2025 WHEATON WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-4300
Mailing Address - Country:US
Mailing Address - Phone:360-479-0809
Mailing Address - Fax:360-377-3577
Practice Address - Street 1:2025 WHEATON WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4300
Practice Address - Country:US
Practice Address - Phone:360-479-0809
Practice Address - Fax:360-377-3577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601433588207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA038299OtherLABOR AND INDUSTRIES
WA013194010OtherGROUP HEALTH COOPERATIVE
WA7077134Medicaid
WA192575000OtherOWCP
WA013194010OtherGROUP HEALTH COOPERATIVE
WA038299OtherLABOR AND INDUSTRIES
WA=========OtherPREMERA BLUE CROSS
WA=========OtherREGENCE
WA7077134Medicaid
WA013194010OtherGROUP HEALTH COOPERATIVE