Basic Information
Provider Information | |||||||||
NPI: | 1235483579 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FMG-FRANCISCAN ORTHOPEDIC ASSOCIATES - ENUMCLAW | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2820 GRIFFIN AVE | ||||||||
Address2: | #210 | ||||||||
City: | ENUMCLAW | ||||||||
State: | WA | ||||||||
PostalCode: | 980222373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608257500 | ||||||||
FaxNumber: | 3608253370 | ||||||||
Practice Location | |||||||||
Address1: | 2820 GRIFFIN AVE | ||||||||
Address2: | #210 | ||||||||
City: | ENUMCLAW | ||||||||
State: | WA | ||||||||
PostalCode: | 980222373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608257500 | ||||||||
FaxNumber: | 3608253370 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2012 | ||||||||
LastUpdateDate: | 11/08/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SPARE | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CMO | ||||||||
AuthorizedOfficialTelephone: | 2537924344 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.