Provider Demographics
NPI:1144297003
Name:TACOMA ENDOSCOPY CENTER
Entity type:Organization
Organization Name:TACOMA ENDOSCOPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:CARROUGHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-272-8664
Mailing Address - Street 1:1112 6TH AVE
Mailing Address - Street 2:200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4040
Mailing Address - Country:US
Mailing Address - Phone:253-272-8664
Mailing Address - Fax:253-404-1352
Practice Address - Street 1:1112 6TH AVE
Practice Address - Street 2:200
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4040
Practice Address - Country:US
Practice Address - Phone:253-272-8664
Practice Address - Fax:253-404-1352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAASF.FS.60099979261QA1903X
WAFX00056070261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA77687OtherLABOR & INDUSTRIES
WA7065394Medicaid
TA2834OtherREGENCE
WA77687OtherLABOR & INDUSTRIES
190003780Medicare ID - Type UnspecifiedRAILROAD MEDICARE