Basic Information
| Provider Information | |||||||||
| NPI: | 1902814833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | FRANCISCAN SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11307 BRIDGEPORT WAY SW | ||||||||
| Address2: | STE 220-A | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539852733 | ||||||||
| FaxNumber: | 2539852868 | ||||||||
| Practice Location | |||||||||
| Address1: | 11307 BRIDGEPORT WAY SW | ||||||||
| Address2: | STE 220-A | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539852733 | ||||||||
| FaxNumber: | 2539852868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 06/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | FIELD | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2538589192 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7124035 | 05 | WA | MEDICAID | 0200031 | 01 | WA | STATE L&I | OTHER |