Basic Information
| Provider Information | |||||||||
| NPI: | 1356309330 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOCTORS CLINIC APC | ||||||||
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| OtherOrganizationName: | THE DOCTORS CLINIC OF EAST BREMERTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9621 RIDGETOP BLVD NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838502 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2512 WHEATON WAY | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607823600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 11/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3607823600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | WA | N | Ambulatory Health Care Facilities | Clinic/Center | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QM1300X | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 8914602 | 01 | WA | CVCP | OTHER | 50D0911681 | 01 | CLIA | OTHER | 75420 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8914602 | 01 | WA | CRIME VICTIMS COMP | OTHER | 7041312 | 05 | WA | MEDICAID | CU0247 | 01 | WA | RAILROAD MEDICARE | OTHER | 20337 | 01 | COAL MINE WORKERS COMP | OTHER | 337018601 | 01 | OWCP | OTHER |