Healthcare Provider Details

I. General information

NPI: 1194045542
Provider Name (Legal Business Name): WESTERN WASHINGTON MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 214TH ST SE SUITE 211
BOTHELL WA
98021-4412
US

IV. Provider business mailing address

1728 W MARINE VIEW DR SUITE 110
EVERETT WA
98201-2094
US

V. Phone/Fax

Practice location:
  • Phone: 425-420-1655
  • Fax:
Mailing address:
  • Phone: 425-259-4041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number207RG0100X
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number207RC0000X
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number207RE0101X
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number213E00000X
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number207Y00000X
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number291U00000X
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number207R00000X
License Number StateWA

VIII. Authorized Official

Name: JEROME TILLINGER
Title or Position: CEO
Credential:
Phone: 425-259-4041