Basic Information
| Provider Information | |||||||||
| NPI: | 1043404163 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROBERT QUACKENBUSH MD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2102 | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993620102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095252220 | ||||||||
| FaxNumber: | 5095254878 | ||||||||
| Practice Location | |||||||||
| Address1: | 40L W POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095252220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2007 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | QUACKENBUSH | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 5095252220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00039975 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | DA4111 | 01 | WA | RRMC | OTHER |