Basic Information
| Provider Information | |||||||||
| NPI: | 1376667907 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNATIONAL COMMUNITY HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INTERNATIONAL DISTRICT CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24911 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981240911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067883600 | ||||||||
| FaxNumber: | 2066525216 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 8TH AVE S | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981043032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067883700 | ||||||||
| FaxNumber: | 2067883706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 12/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | PHUNG | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT FINANCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2067883605 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTERNATIONAL COMMUNITY HEALTH SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7900012 | 05 | WA | MEDICAID |