Provider Demographics
NPI:1285978882
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:DIRECTOR PFS
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-4041
Mailing Address - Street 1:1728 W MARINE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2094
Mailing Address - Country:US
Mailing Address - Phone:425-259-4041
Mailing Address - Fax:
Practice Address - Street 1:4404 80TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-3427
Practice Address - Country:US
Practice Address - Phone:360-659-1231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WASHINGTON MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-20
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty