Basic Information
Provider Information | |||||||||
NPI: | 1134377070 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FMG-NORTHWEST NEPHROLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1708 YAKIMA AVE | ||||||||
Address2: | #107 | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984055307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2532725881 | ||||||||
FaxNumber: | 2533830161 | ||||||||
Practice Location | |||||||||
Address1: | 1708 YAKIMA AVE | ||||||||
Address2: | #107 | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984055307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2532725881 | ||||||||
FaxNumber: | 2533830161 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/04/2008 | ||||||||
LastUpdateDate: | 09/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROBERTSON | ||||||||
AuthorizedOfficialFirstName: | CLIFF | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2537796101 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X |   | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.