Healthcare Provider Details

I. General information

NPI: 1356486260
Provider Name (Legal Business Name): FRANCISCAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 CENTER DR #130
DUPONT WA
98327-7733
US

IV. Provider business mailing address

1175 CENTER DR #130
DUPONT WA
98327-7733
US

V. Phone/Fax

Practice location:
  • Phone: 253-539-9735
  • Fax: 253-539-7981
Mailing address:
  • Phone: 253-964-5260
  • Fax: 253-964-5266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00002173
License Number StateWA

VIII. Authorized Official

Name: CLIFF A. ROBERTSON
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 253-779-6101