Provider Demographics
NPI:1730180746
Name:CREEKSIDE ORTHOPEDICS, PLLC
Entity type:Organization
Organization Name:CREEKSIDE ORTHOPEDICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-457-1900
Mailing Address - Street 1:PO BOX 8051
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-0051
Mailing Address - Country:US
Mailing Address - Phone:509-469-1903
Mailing Address - Fax:509-469-1905
Practice Address - Street 1:3907 CREEKSIDE LOOP
Practice Address - Street 2:STE. 100
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4879
Practice Address - Country:US
Practice Address - Phone:509-457-1900
Practice Address - Fax:509-853-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0012321174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7126642Medicaid
WA0197897OtherLABOR AND INDUSTRIES
WA7126642Medicaid
WADC6949Medicare PIN
WAP00184475Medicare PIN
WAG8850405Medicare PIN