Provider Demographics
NPI:1538253331
Name:SOUTH HILL FAMILY MEDICINE PC
Entity type:Organization
Organization Name:SOUTH HILL FAMILY MEDICINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RHIANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BROVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-848-5951
Mailing Address - Street 1:3908 10TH ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2188
Mailing Address - Country:US
Mailing Address - Phone:253-848-5951
Mailing Address - Fax:253-864-8954
Practice Address - Street 1:3908 10TH ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2188
Practice Address - Country:US
Practice Address - Phone:253-848-5951
Practice Address - Fax:253-864-8954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601290482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0169201OtherL& I GROUP NUMBER
WA7036114Medicaid
WA7036114Medicaid
WA115130300Medicare ID - Type UnspecifiedGROUP NUMBER
WACN7050Medicare ID - Type UnspecifiedRAIL ROAD