MEDICARE: SOUTH WHIDBEY PEDIATRICS

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	208000000X	Pediatrics Physician	MD00020537	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	:	1194045708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH WHIDBEY PEDIATRICS

Provider Business Mailing Address
First Line	:	PO BOX 8
Second Line	:
City	:	FREELAND
State	:	WA
Zip	:	98249
Country	:	US
Telephone Number	:	360-331-1314
Fax Number	:

Provider Business Practice Location Address
First Line	:	1690 LAYTON RD
Second Line	:
City	:	FREELAND
State	:	WA
Zip	:	98249-9456
Country	:	US
Telephone Number	:	360-331-1314
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	SUSAN WAGNER
Credential	:
Telephone Number	:	360-331-1314

Provider Enumeration Date	:	06/04/2010
Last Update Date	:	06/04/2010

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