Healthcare Provider Details

I. General information

NPI: 1053641183
Provider Name (Legal Business Name): MOUNT RAINIER UROLOGY, INC, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 LILLY RD NE SUITE 106
OLYMPIA WA
98506-5191
US

IV. Provider business mailing address

703 LILLY RD NE SUITE 106
OLYMPIA WA
98506-5191
US

V. Phone/Fax

Practice location:
  • Phone: 360-350-0281
  • Fax: 360-918-8280
Mailing address:
  • Phone: 360-350-0281
  • Fax: 360-918-8280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD 60116602
License Number StateWA

VIII. Authorized Official

Name: DR. SIMON PHILIP ZADINA
Title or Position: PRESIDENT & SOLO PRACTITIONER
Credential: M.D.
Phone: 360-350-0281