Provider Demographics
NPI:1568916682
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:CONTRACT ANALYST/CREDENTIALING COOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BAE
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:SUITE 110
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 1:12728 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:425-259-4041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical CareGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty