Basic Information
| Provider Information | |||||||||
| NPI: | 1083785398 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLYMPIA ORTHOPAEDIC ASSOCIATES PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OLYMPIA SURGERY CENTER LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 368 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985070368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604918439 | ||||||||
| FaxNumber: | 3604916328 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 CAPITAL MALL DR SW STE B | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985028654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604918439 | ||||||||
| FaxNumber: | 3604916328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3604555144 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 7066269 | 05 | WA | MEDICAID | 7111289 | 05 | WA | MEDICAID |