=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699755652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISSAQUAH INTERNAL MEDICINE ASSOCIATES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2006
-----------------------------------------------------
Last Update Date | 05/31/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 NW GILMAN BLVD STE 301A
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-391-0313
-----------------------------------------------------
Fax | 425-837-8501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1225
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-0047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-391-0313
-----------------------------------------------------
Fax | 425-837-8501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | VICKI M ROUILLARD
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 425-391-0313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD00032314
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------