MEDICARE: MADRONA FAMILY MEDICINE, PS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD00031142	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154528156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADRONA FAMILY MEDICINE, PS

Provider Business Mailing Address
First Line	:	PO BOX 1212
Second Line	:
City	:	PORT TOWNSEND
State	:	WA
Zip	:	98368-0912
Country	:	US
Telephone Number	:	360-440-6220
Fax Number	:

Provider Business Practice Location Address
First Line	:	740 QUINCY ST
Second Line	:
City	:	PORT TOWNSEND
State	:	WA
Zip	:	98368-5525
Country	:	US
Telephone Number	:	360-440-6220
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRUCE WALLACE STOWE
Credential	:	M.D.
Telephone Number	:	360-440-6220

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	09/06/2013

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