=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912010984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KITSAP GENERAL SURGERY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2006
-----------------------------------------------------
Last Update Date | 11/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9927 MICKELBERRY RD NW SUITE 121
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-9195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-613-1335
-----------------------------------------------------
Fax | 360-613-1329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9927 MICKELBERRY RD NW SUITE 121
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-9195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-613-1335
-----------------------------------------------------
Fax | 360-613-1329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIANPARTNER
-----------------------------------------------------
Name | TY CHUN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 360-613-1335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------