Basic Information
| Provider Information | |||||||||
| NPI: | 1346276797 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF WASHINGTON, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAVITA NEPHROLOGY PARTNERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9429 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049159429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036266239 | ||||||||
| FaxNumber: | 8669175396 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 BRADLEY BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993524381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415641810 | ||||||||
| FaxNumber: | 5415641812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | GABRIEL | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3105362615 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 7126378 | 05 | WA | MEDICAID | G8851020 | 01 | WA | MEDICARE GROUP NUMBER | OTHER |