NPIMap

Organization Active NPI

Rejuvenation Medical PLLC

  • Family Medicine Physician
  • Shoreline, WA
National Provider Identifier
1447712559
Registry record updated Apr 5, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
REJUVENATION MEDICAL PLLC
Practice address
20011 Ballinger Way NE
Shoreline, WA 98155-1286
Phone
(206) 407-4171
Fax
(206) 906-9981
NPI assigned
Apr 5, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 5, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Joshua KretchmarNPI 1629485701
Title
DO
Phone
(817) 789-2639

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

20011 Ballinger Way NE
Shoreline, WA 98155-1286

Mailing address

20011 Ballinger Way NE
Shoreline, WA 98155-1286
Phone (206) 407-4171

Other identifiers 1

IdentifierTypeStateIssuer
OP60765453OtherWALICENSE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211109001571 WA Part B Supplier - Clinic/Group Practice 4880083062 Receives reassigned benefits from 21 practitioners
Practice locations: Auburn, WA; Tukwila, WA; Tacoma, WA; Seattle, WA; Puyallup, WA; Port Orchard, WA; Kirkland, WA; Edgewood, WA…

National Provider Directory

National Provider Directory

Locations

826 S 218th St
Des Moines, WA 98198
Phone (206) 824-5000

2222 Meridian Ave E
Ste A
Edgewood, WA 98371
Phone (206) 407-4171

2222 Meridian Ave E
Edgewood, WA 98371

19435 68th Ave S
Ste 101
Kent, WA 98032

19435 68th Ave S
Ste S101
Kent, WA 98032
Phone (206) 407-4171

1314 Central Ave S
Ste 102
Kent, WA 98032
Phone (253) 397-8683

20011 Ballinger Way NE
Ste C100
Shoreline, WA 98155
Phone (206) 367-6069

20011 Ballinger Way NE
Shoreline, WA 98155
Phone (206) 407-4171

Practitioners & affiliated clinicians

Practitioners 23

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 23

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1554422400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1554422400000",
    "number": "1447712559",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "20011 BALLINGER WAY NE",
            "city": "SHORELINE",
            "state": "WA",
            "postal_code": "981551286",
            "telephone_number": "206-407-4171"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20011 BALLINGER WAY NE",
            "city": "SHORELINE",
            "state": "WA",
            "postal_code": "981551286",
            "telephone_number": "206-407-4171",
            "fax_number": "206-906-9981"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REJUVENATION MEDICAL PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-04-05",
        "last_updated": "2019-04-05",
        "status": "A",
        "authorized_official_last_name": "KRETCHMAR",
        "authorized_official_first_name": "JOSHUA",
        "authorized_official_title_or_position": "DO",
        "authorized_official_telephone_number": "817-789-2639"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "OP60765453",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Shoreline, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 5, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.