Provider Demographics
NPI:1306295605
Name:LORRAINE ROBERTSONMD
Entity type:Organization
Organization Name:LORRAINE ROBERTSONMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-985-6241
Mailing Address - Street 1:12520 SUNRISE DR NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-4307
Mailing Address - Country:US
Mailing Address - Phone:425-985-6241
Mailing Address - Fax:206-201-3836
Practice Address - Street 1:12520 SUNRISE DR NE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-4307
Practice Address - Country:US
Practice Address - Phone:425-985-6241
Practice Address - Fax:206-201-3836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1300896Medicaid
WAR04771OtherREGENCE RIDER #
WAAB35212OtherMEDICARE ID- UNSPECIFIED
WAA06226Medicare UPIN