Healthcare Provider Details

I. General information

NPI: 1245566348
Provider Name (Legal Business Name): KITSAP COLORECTAL SURGERY INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2528 WHEATON WAY SUITE 103
BREMERTON WA
98310-3305
US

IV. Provider business mailing address

2528 WHEATON WAY SUITE 103
BREMERTON WA
98310-3305
US

V. Phone/Fax

Practice location:
  • Phone: 360-377-4717
  • Fax: 360-377-4134
Mailing address:
  • Phone: 360-377-4717
  • Fax: 360-377-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35113
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number35113
License Number StateWA

VIII. Authorized Official

Name: DR. JOHNNY B GREEN
Title or Position: PRESIDENT
Credential: MD
Phone: 360-377-4717