Healthcare Provider Details

I. General information

NPI: 1548210719
Provider Name (Legal Business Name): PEDIATRIC CRITICAL CARE ASSOCIATES PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 8TH AVE
SPOKANE WA
99204-2307
US

IV. Provider business mailing address

PO BOX 84301
SEATTLE WA
98124-5601
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-7461
  • Fax: 509-474-5233
Mailing address:
  • Phone: 509-926-1770
  • Fax: 509-228-9542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER W GRAVES
Title or Position: SECRETERY TRESURER
Credential: MD
Phone: 509-474-5233