Basic Information
| Provider Information | |||||||||
| NPI: | 1043578776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUGET SOUND RHEUMATOLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 97115 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984970115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535887911 | ||||||||
| FaxNumber: | 2539846774 | ||||||||
| Practice Location | |||||||||
| Address1: | 20700 BOND RD NE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | POULSBO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983709099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603863897 | ||||||||
| FaxNumber: | 8886402325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | BALENTINE | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2535887911 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | MD60036029 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | MD60036029 | 01 | WA | MEDICAL LICENSE | OTHER |