Basic Information
| Provider Information | |||||||||
| NPI: | 1629016522 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THORACIC & VASCULAR CENTER OF KITSAP COUNTY INC PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 CAMPBELL WAY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604794228 | ||||||||
| FaxNumber: | 3604787240 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 CAMPBELL WAY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604794228 | ||||||||
| FaxNumber: | 3604787240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 09/25/2007 | ||||||||
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| AuthorizedOfficialLastName: | BERNI | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3604794228 | ||||||||
| 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 | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7116726 | 05 | WA | MEDICAID |