Basic Information
| Provider Information | |||||||||
| NPI: | 1316914278 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARBOR ENDOSCOPY CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1112 6TH AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728664 | ||||||||
| FaxNumber: | 2534041352 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 POINT FOSDICK DR NW | ||||||||
| Address2: | 308 | ||||||||
| City: | GIG HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983351706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728664 | ||||||||
| FaxNumber: | 2534041352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 01/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | CARROUGHER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2532728664 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | ASF.FX.60100031 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QE0800X | FX00057739 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 7119621 | 05 | WA | MEDICAID | 193456 | 01 | WA | LABOR & INDUSTRIES | OTHER |