=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447208293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRANCISCAN MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 06/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1708 YAKIMA AVE STE 105
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98405-5307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-426-4420
-----------------------------------------------------
Fax | 253-426-4383
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1708 YAKIMA AVE STE 105
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98405-5307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-426-4420
-----------------------------------------------------
Fax | 253-426-4383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL OFFICER
-----------------------------------------------------
Name | CLIFF ROBERTSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 253-779-6101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------