Basic Information
| Provider Information | |||||||||
| NPI: | 1417983867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TACOMA DIGESTIVE DISEASE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1112 6TH AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728664 | ||||||||
| FaxNumber: | 2534041352 | ||||||||
| Practice Location | |||||||||
| Address1: | 1112 6TH AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728664 | ||||||||
| FaxNumber: | 2534041352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAERG | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2532728664 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | CD9272 | 01 | RAILROAD MEDICARE | OTHER | 0077665 | 01 | WA | LABOR & INDUSTRIES | OTHER | 7079247 | 05 | WA | MEDICAID | P07414 | 01 | REGENCE BLUE SHIELD | OTHER |