Healthcare Provider Details

I. General information

NPI: 1780522615
Provider Name (Legal Business Name): WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 214TH ST SE STE 205
BOTHELL WA
98021-4415
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 425-259-4041
  • Fax:
Mailing address:
  • Phone: 425-259-4041
  • Fax: 425-740-4155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID RUSSIAN
Title or Position: CEO
Credential: MD
Phone: 425-259-4041