Healthcare Provider Details

I. General information

NPI: 1538606413
Provider Name (Legal Business Name): WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
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 SUITE 110
EVERETT WA
98201-2094
US

V. Phone/Fax

Practice location:
  • Phone: 425-248-2626
  • Fax: 425-248-2627
Mailing address:
  • Phone: 425-248-2626
  • Fax: 425-248-2627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ELIZABETH BAE
Title or Position: CONTRACT ANALYST AND CREDENTIALING
Credential:
Phone: 425-740-5032