Basic Information
| Provider Information | |||||||||
| NPI: | 1053559682 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | FMG-FRANCISCAN ACUTE SURGICAL TEAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11307 BRIDGEPORT WAY SW | ||||||||
| Address2: | STE 220 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539856141 | ||||||||
| FaxNumber: | 2539852868 | ||||||||
| Practice Location | |||||||||
| Address1: | 11307 BRIDGEPORT WAY SW | ||||||||
| Address2: | STE 220 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539856141 | ||||||||
| FaxNumber: | 2539852868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2009 | ||||||||
| LastUpdateDate: | 02/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | CLIFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2536804014 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.