Healthcare Provider Details

I. General information

NPI: 1962938183
Provider Name (Legal Business Name): MEMORIAL PHYSICIANS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2017
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E JACKSON AVE SUITE 102
ELLENSBURG WA
98926-3692
US

IV. Provider business mailing address

3800 SUMMITVIEW AVE
YAKIMA WA
98902-2715
US

V. Phone/Fax

Practice location:
  • Phone: 509-453-4614
  • Fax: 509-225-2712
Mailing address:
  • Phone: 509-453-4614
  • Fax: 509-225-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number602902835
License Number StateWA

VIII. Authorized Official

Name: TIMOTHY REED
Title or Position: CFO. VP
Credential:
Phone: 509-248-7849