Basic Information
| Provider Information | |||||||||
| NPI: | 1356560056 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FMG-FEDERAL WAY ORTHOPEDIC ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34709 9TH AVE S | ||||||||
| Address2: | #B-500 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538388552 | ||||||||
| FaxNumber: | 2538746089 | ||||||||
| Practice Location | |||||||||
| Address1: | 34709 9TH AVE S | ||||||||
| Address2: | #B-500 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538388552 | ||||||||
| FaxNumber: | 2538746089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 06/14/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | CLIFF | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537796101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0219676 | 01 | WA | STATE L&I | OTHER | 7137094 | 05 | WA | MEDICAID |