Healthcare Provider Details

I. General information

NPI: 1184088155
Provider Name (Legal Business Name): SAMUEL ROTH SKOVGAARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 10/04/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 S PEABODY ST
PORT ANGELES WA
98362-6229
US

IV. Provider business mailing address

519 S PEABODY ST
PORT ANGELES WA
98362-6229
US

V. Phone/Fax

Practice location:
  • Phone: 360-417-7000
  • Fax: 360-565-9241
Mailing address:
  • Phone: 360-565-9237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD61321058
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: