Basic Information
| Provider Information | |||||||||
| NPI: | 1447413091 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHIDBEY ISLAND PUBLIC HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WHIDBEYHEALTH SURGICAL CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 101 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COUPEVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982393413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606785151 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 205 S MAIN STREET | ||||||||
| Address2: | A | ||||||||
| City: | COUPEVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606786799 | ||||||||
| FaxNumber: | 3606786654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TELLES | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3606787656 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHIDBEY ISLAND PUBLIC HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | H156 | WA | N | Hospitals | General Acute Care Hospital | Critical Access | 208600000X | H156 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.