=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649476755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT W. KUNKLE MD, INC PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2007
-----------------------------------------------------
Last Update Date | 12/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6712 KIMBALL DR STE 101
-----------------------------------------------------
City | GIG HARBOR
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98335-1212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-853-3100
-----------------------------------------------------
Fax | 253-549-2367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 439 6TH AVE
-----------------------------------------------------
City | FOX ISLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98333-9715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-853-3100
-----------------------------------------------------
Fax | 253-549-2367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER
-----------------------------------------------------
Name | MRS. BARBARA A ZIMMERMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-514-5687
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD00028126
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------