Healthcare Provider Details

I. General information

NPI: 1275647422
Provider Name (Legal Business Name): SOUTHWEST WASHINGTON THORACIC AND VASCULAR SURGERY PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NE MOTHER JOSEPH PL SUITE 330
VANCOUVER WA
98664-3299
US

IV. Provider business mailing address

312 SE STONEMILL DR. SUITE 160
VANCOUVER WA
98684-3514
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-1854
  • Fax: 360-514-6063
Mailing address:
  • Phone: 360-735-3480
  • Fax: 360-735-3481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KURT C LITVIN
Title or Position: EXEC. DIRECTOR
Credential:
Phone: 360-735-8100