Basic Information
| Provider Information | |||||||||
| NPI: | 1952434268 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLYMPIC MEDICAL SPECIALTY CLINIC - SEQUIM | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 840 NORTH 5TH AVENUE | ||||||||
| Address2: | SUITE 1500 | ||||||||
| City: | SEQUIM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605822840 | ||||||||
| FaxNumber: | 3605822841 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 NORTH 5TH AVENUE | ||||||||
| Address2: | SUITE 1500 | ||||||||
| City: | SEQUIM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605822840 | ||||||||
| FaxNumber: | 3605822841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 06/05/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CORLEY | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3605822840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.