Provider Demographics
NPI:1003169434
Name:UROLOGY NORTHWEST, PS
Entity type:Organization
Organization Name:UROLOGY NORTHWEST, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDY
Authorized Official - Middle Name:SHALON
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-275-5547
Mailing Address - Street 1:6005 244TH ST SW
Mailing Address - Street 2:111
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-5400
Mailing Address - Country:US
Mailing Address - Phone:425-275-5547
Mailing Address - Fax:425-275-5593
Practice Address - Street 1:3100 TONGASS AVE
Practice Address - Street 2:3RD FLOOR VISITING CLINIC
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5746
Practice Address - Country:US
Practice Address - Phone:855-881-5319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UROLOGY NORTHWEST, PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMPG0374Medicaid
AKK164231Medicare PIN