Basic Information
| Provider Information | |||||||||
| NPI: | 1558478818 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PORT ORCHARD MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 451 SW SEDGWICK RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608745900 | ||||||||
| FaxNumber: | 3608745959 | ||||||||
| Practice Location | |||||||||
| Address1: | 451 SW SEDGWICK RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608745900 | ||||||||
| FaxNumber: | 3608745959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 03/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | FIELD | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 2538589192 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OP00001963 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7132459 | 05 | WA | MEDICAID | 0207870 | 01 | WA | STATE L&I | OTHER | 8928223 | 01 | WA | STATE CRIME VICTIMS | OTHER |