Basic Information
| Provider Information | |||||||||
| NPI: | 1972722510 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | HIGHLINE FOOT & ANKLE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16233 SYLVESTER RD SW | ||||||||
| Address2: | #G-10 | ||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981663045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062426553 | ||||||||
| FaxNumber: | 2064260468 | ||||||||
| Practice Location | |||||||||
| Address1: | 16233 SYLVESTER RD SW | ||||||||
| Address2: | #G-10 | ||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981663045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062426553 | ||||||||
| FaxNumber: | 2064260468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 06/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | CLIFF | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537796101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0004X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0223400 | 01 | WA | STATE L&I | OTHER | 7137110 | 05 | WA | MEDICAID |