Provider Demographics
NPI:1699755652
Name:ISSAQUAH INTERNAL MEDICINE ASSOCIATES, PLLC
Entity type:Organization
Organization Name:ISSAQUAH INTERNAL MEDICINE ASSOCIATES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROUILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-391-0313
Mailing Address - Street 1:PO BOX 1225
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-0047
Mailing Address - Country:US
Mailing Address - Phone:425-391-0313
Mailing Address - Fax:425-837-8501
Practice Address - Street 1:450 NW GILMAN BLVD STE 301A
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027
Practice Address - Country:US
Practice Address - Phone:425-391-0313
Practice Address - Fax:425-837-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032314207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7090491Medicaid
CN9619OtherRAILROAD MEDICARE
WA123345OtherDEPT OF LABOR AND INDUSTR
WA123345OtherDEPT OF LABOR AND INDUSTR