Healthcare Provider Details

I. General information

NPI: 1205805264
Provider Name (Legal Business Name): KITSAP INTERNAL MEDICINE ASSOCIATES, INC, P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 CHERRY AVE SUITE 315
BREMERTON WA
98310-4203
US

IV. Provider business mailing address

2601 CHERRY AVE SUITE 315
BREMERTON WA
98310-4203
US

V. Phone/Fax

Practice location:
  • Phone: 360-377-8571
  • Fax: 360-792-1608
Mailing address:
  • Phone: 360-377-8571
  • Fax: 360-792-1608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number600150638
License Number StateWA

VIII. Authorized Official

Name: MRS. CAROL M AXTMAN
Title or Position: MANAGER
Credential:
Phone: 360-377-8571