Basic Information
Provider Information | |||||||||
NPI: | 1386864148 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTERNATIONAL COMMUNITY HEALTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOLLY PARK MEDICAL AND DENTAL CLINIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 24911 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981240911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2067883600 | ||||||||
FaxNumber: | 2066525216 | ||||||||
Practice Location | |||||||||
Address1: | 3815 S OTHELLO ST | ||||||||
Address2: | 2ND FL. | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981183510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2067883500 | ||||||||
FaxNumber: | 2067883521 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2007 | ||||||||
LastUpdateDate: | 12/20/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PHUNG | ||||||||
AuthorizedOfficialFirstName: | PEGGY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT FINANCE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2067883605 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | INTERNATIONAL COMMUNITY HEALTH SERVICES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 | 7094196 | 05 | WA |   | MEDICAID | 7125297 | 05 | WA |   | MEDICAID |