Basic Information
| Provider Information | |||||||||
| NPI: | 1649484833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLYMPIC PHYSICIANS P.L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 237 PROFESSIONAL WAY | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604262500 | ||||||||
| FaxNumber: | 3604262787 | ||||||||
| Practice Location | |||||||||
| Address1: | 237 PROFESSIONAL WAY | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604262500 | ||||||||
| FaxNumber: | 3604262787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 10/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | SCHLAUDERAFF | ||||||||
| AuthorizedOfficialFirstName: | PAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3604262500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00042875 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | OP00001739 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | MD00045960 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | PA10004942 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207R00000X | MD00047153 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD00019248 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7090947 | 05 | WA | MEDICAID |