Basic Information
| Provider Information | |||||||||
| NPI: | 1255736104 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDMONDS FAMILY MEDICINE CLINIC PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7315 212TH ST SW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257759474 | ||||||||
| FaxNumber: | 4256703554 | ||||||||
| Practice Location | |||||||||
| Address1: | 7315 212TH ST SW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257759474 | ||||||||
| FaxNumber: | 4256703554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 11/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHIMADA | ||||||||
| AuthorizedOfficialFirstName: | MARCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4256703555 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.