Healthcare Provider Details

I. General information

NPI: 1568916682
Provider Name (Legal Business Name): WESTERN WASHINGTON MEDICAL GROUP INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 06/19/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12728 19TH AVE SE SUITE 300
EVERETT WA
98208-6526
US

IV. Provider business mailing address

1728 W MARINE VIEW DR SUITE 110
EVERETT WA
98201-2094
US

V. Phone/Fax

Practice location:
  • Phone: 425-259-4041
  • Fax:
Mailing address:
  • Phone: 425-259-4041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH BAE
Title or Position: CONTRACT ANALYST/CREDENTIALING COOR
Credential:
Phone: 425-259-4041