Basic Information
| Provider Information | |||||||||
| NPI: | 1962722868 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | FRANCISCAN NEUROLOGY CLINIC - LAKEWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11311 BRIDGEPORT WAY SW | ||||||||
| Address2: | STE 205 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535524102 | ||||||||
| FaxNumber: | 2535524175 | ||||||||
| Practice Location | |||||||||
| Address1: | 11311 BRIDGEPORT WAY SW | ||||||||
| Address2: | STE 205 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535524102 | ||||||||
| FaxNumber: | 2535524175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2010 | ||||||||
| LastUpdateDate: | 06/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | FIELD | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 2536804009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.