Provider Demographics
NPI:1548368798
Name:MICHAEL S. EICKERMAN M.D. PS
Entity type:Organization
Organization Name:MICHAEL S. EICKERMAN M.D. PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:EICKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-794-1415
Mailing Address - Street 1:19030 LENTON PL SE PMB 608
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1353
Mailing Address - Country:US
Mailing Address - Phone:360-794-1415
Mailing Address - Fax:360-805-3456
Practice Address - Street 1:14841 179TH AVE SE STE 140
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1127
Practice Address - Country:US
Practice Address - Phone:360-794-1415
Practice Address - Fax:360-805-3456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1103571Medicaid
WA1103571Medicaid
WAGAB03384Medicare ID - Type Unspecified