Basic Information
Provider Information | |||||||||
NPI: | 1891729901 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FRANCISCAN MEDICAL CLINIC-FEDERAL WAY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 30809 1ST AVE S | ||||||||
Address2: |   | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980034074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538392030 | ||||||||
FaxNumber: | 2538391091 | ||||||||
Practice Location | |||||||||
Address1: | 30809 1ST AVE S | ||||||||
Address2: |   | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980034074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538392030 | ||||||||
FaxNumber: | 2538391091 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 07/02/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROBERTSON | ||||||||
AuthorizedOfficialFirstName: | CLIFF | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2537796101 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 247100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 7128630 | 05 | WA |   | MEDICAID | 0199167 | 01 | WA | STATE L&I | OTHER |