Basic Information
| Provider Information | |||||||||
| NPI: | 1265643803 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FRANCISCAN MEDICAL CLINIC-PT. FOSDICK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4700 POINT FOSDICK DR NW | ||||||||
| Address2: | STE 202 | ||||||||
| City: | GIG HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983351706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538571450 | ||||||||
| FaxNumber: | 2538571489 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 POINT FOSDICK DR NW | ||||||||
| Address2: | STE 202 | ||||||||
| City: | GIG HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983351706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538571450 | ||||||||
| FaxNumber: | 2538571489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 07/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | CLIFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 2537796101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OP00001673 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7138506 | 05 | WA | MEDICAID | 0223265 | 01 | WA | STATE L&I | OTHER |