Basic Information
| Provider Information | |||||||||
| NPI: | 1962417659 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SURPRISE LAKE MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2748 MILTON WAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MILTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983549382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539225262 | ||||||||
| FaxNumber: | 2539225299 | ||||||||
| Practice Location | |||||||||
| Address1: | 2748 MILTON WAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MILTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983549382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539225262 | ||||||||
| FaxNumber: | 2539225299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 06/14/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | CLIFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537796101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7124365 | 05 | WA | MEDICAID | 0105765 | 01 | WA | STATE L&I | OTHER |