MEDICARE: WESTERN WASHINGTON MEDICAL GROUP, INC 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	207RN0300X	Nephrology Physician	601474013	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CJ9333	OTHER	WA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0050081	OTHER	WA	LABOR & INDUSTRY
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417175811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN WASHINGTON MEDICAL GROUP, INC PS

Provider Business Mailing Address
First Line	:	12728 19TH AVE SE STE 300
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98208-6676
Country	:	US
Telephone Number	:	425-252-1116
Fax Number	:	425-252-1118

Provider Business Practice Location Address
First Line	:	12728 19TH AVE SE STE 300
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98208-6676
Country	:	US
Telephone Number	:	425-258-6801
Fax Number	:	425-258-1944

Authorized Official
Title or Position	:	HIPPA PRIVACY OFFICER
Name	:	MS. VICKI MCGINNIS
Credential	:
Telephone Number	:	425-259-4041

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	05/24/2024

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