Basic Information
Provider Information | |||||||||
NPI: | 1144297003 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TACOMA ENDOSCOPY CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1112 6TH AVE | ||||||||
Address2: | 200 | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984054040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2532728664 | ||||||||
FaxNumber: | 2534041352 | ||||||||
Practice Location | |||||||||
Address1: | 1112 6TH AVE | ||||||||
Address2: | 200 | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984054040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2532728664 | ||||||||
FaxNumber: | 2534041352 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2006 | ||||||||
LastUpdateDate: | 01/14/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARROUGHER | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2532728664 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | ASF.FS.60099979 | WA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QE0800X | FX00056070 | WA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
ID | Type | State | Issuer | Description | 77687 | 01 | WA | LABOR & INDUSTRIES | OTHER | 7065394 | 05 | WA |   | MEDICAID | TA2834 | 01 |   | REGENCE | OTHER |