Healthcare Provider Details

I. General information

NPI: 1518140094
Provider Name (Legal Business Name): PACIFIC COLON AND RECTAL CLINIC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 05/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 NE 130TH LN SUITE 530
KIRKLAND WA
98034-3099
US

IV. Provider business mailing address

12303 NE 130TH LN SUITE 530
KIRKLAND WA
98034-3099
US

V. Phone/Fax

Practice location:
  • Phone: 425-899-4600
  • Fax:
Mailing address:
  • Phone: 425-899-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD00030958
License Number StateWA

VIII. Authorized Official

Name: JAMES G HIBBERT
Title or Position: OWNER
Credential: MD
Phone: 425-899-4600