Basic Information
| Provider Information | |||||||||
| NPI: | 1356716351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAINIER INTERNAL MEDICINE LLC | ||||||||
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| OtherOrganizationName: | NORTHWEST INTEGRATED HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 19680 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535033666 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3800 3RD ST SE | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983741109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532000415 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2015 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | ASIF | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2536665912 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | CP60560378 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 2001900 | 05 | WA | MEDICAID |