Provider Demographics
NPI:1528370723
Name:WESTERN WASHINGTON MEDICAL GROUP, INC
Entity type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:425-740-4149
Mailing Address - Street 1:3726 BROADWAY STE 201
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3788
Mailing Address - Country:US
Mailing Address - Phone:425-317-9119
Mailing Address - Fax:425-317-9118
Practice Address - Street 1:3726 BROADWAY STE 201
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3788
Practice Address - Country:US
Practice Address - Phone:425-317-9119
Practice Address - Fax:425-317-9118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty