Basic Information
| Provider Information | |||||||||
| NPI: | 1316123581 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARIBOU TRAIL PROFESSIONAL MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 220 | ||||||||
| Address2: | 520 W INDIAN AVE | ||||||||
| City: | BREWSTER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988120220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098261760 | ||||||||
| FaxNumber: | 5098269927 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 W INDIAN AVE | ||||||||
| Address2: | |||||||||
| City: | BREWSTER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988120220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098261760 | ||||||||
| FaxNumber: | 5098269927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2008 | ||||||||
| LastUpdateDate: | 11/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BILLING | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5098261760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | OP00000831 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.