Provider Demographics
NPI:1588052245
Name:NORTHWEST MEDICAL SPECIALTIES, PLLC
Entity type:Organization
Organization Name:NORTHWEST MEDICAL SPECIALTIES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:V
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-428-8700
Mailing Address - Street 1:1624 S I ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5016
Mailing Address - Country:US
Mailing Address - Phone:253-428-8700
Mailing Address - Fax:253-383-3376
Practice Address - Street 1:2920 S MERIDIAN
Practice Address - Street 2:SUITE 100
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-1428
Practice Address - Country:US
Practice Address - Phone:253-841-4296
Practice Address - Fax:253-841-2435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60274322207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60274322OtherLICENSE