Basic Information
| Provider Information | |||||||||
| NPI: | 1558397042 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST MEDICAL ASSOCIATES,PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 NE PARK PLAZA DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986845895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602548025 | ||||||||
| FaxNumber: | 3602548618 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 NE PARK PLAZA DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986845895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602548025 | ||||||||
| FaxNumber: | 3602548618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 01/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | SUGARMAN | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3602548025 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 7044142 | 05 | WA | MEDICAID | CO3313 | 01 | WA | RAILROAD MEDICARE | OTHER |