Provider Demographics
NPI:1356422588
Name:EASTERN WASHINGTON DERMATOLOGY PLLC
Entity type:Organization
Organization Name:EASTERN WASHINGTON DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-525-9404
Mailing Address - Street 1:228 W BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2935
Mailing Address - Country:US
Mailing Address - Phone:509-525-9904
Mailing Address - Fax:509-525-9433
Practice Address - Street 1:228 W BIRCH ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2935
Practice Address - Country:US
Practice Address - Phone:509-525-9904
Practice Address - Fax:509-525-9433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8857673Medicare PIN
WA6263030001Medicare NSC