Basic Information
| Provider Information | |||||||||
| NPI: | 1548210719 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC CRITICAL CARE ASSOCIATES PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 84301 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981245601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099261770 | ||||||||
| FaxNumber: | 5092289542 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094747461 | ||||||||
| FaxNumber: | 5094745233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | GRAVES | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETERY TRESURER | ||||||||
| AuthorizedOfficialTelephone: | 5094745233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 2080P0203X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7055130 | 05 | WA | MEDICAID | 7108640 | 05 | WA | MEDICAID |