Basic Information
| Provider Information | |||||||||
| NPI: | 1417977208 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC RIM ORTHOPAEDIC SURGEONS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2979 SQUALICUM PKWY | ||||||||
| Address2: | SUITE #203 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607337670 | ||||||||
| FaxNumber: | 3606471901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2979 SQUALICUM PKWY | ||||||||
| Address2: | SUITE #203 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607337670 | ||||||||
| FaxNumber: | 3606471901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | GANNON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | KEVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 3607337670 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD0022602 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 602120520 | 01 | WA | UBI | OTHER |