Basic Information
| Provider Information | |||||||||
| NPI: | 1952356404 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MULTICARE HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TACOMA GENERAL/ALLENMORE ER DEPT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 315 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534031050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 315 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534031050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHMITZ | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2534598000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 261QC0050X | N | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital | 261QE0002X | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 261QH0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QM2500X | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 45281 | 01 | WA | STATE L&I - AH | OTHER | 7074636 | 05 | WA | MEDICAID | 39086 | 01 | WA | STATE L&I - TG | OTHER |