NPIMap

Organization Active NPI

Impact Physician Group, Washington LLC

  • Internal Medicine Physician
  • Vancouver, WA
National Provider Identifier
1457008971
Registry record updated Mar 4, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
IMPACT PHYSICIAN GROUP, WASHINGTON LLC
Practice address
2805 NE 129TH St
Vancouver, WA 98686-3324
Phone
(360) 356-1890
NPI assigned
Mar 4, 2022
Last updated
Mar 4, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 4, 2022

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

Authorized official

Name
Mr. Paul Miller
Title
Ceo
Phone
(678) 967-5599

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU Primary

Addresses

Primary practice location

2805 NE 129TH St
Vancouver, WA 98686-3324

Mailing address

21 Eastbrook BND Ste 218
Peachtree City, GA 30269-1546
Phone (678) 967-5599

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220411001301 WA Part B Supplier - Clinic/Group Practice 7315333838 Receives reassigned benefits from 12 practitioners
Practice locations: Vancouver, WA

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

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

{
    "created_epoch": "1646352000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1646352000000",
    "number": "1457008971",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21 EASTBROOK BND STE 218",
            "city": "PEACHTREE CITY",
            "state": "GA",
            "postal_code": "302691546",
            "telephone_number": "678-967-5599"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2805 NE 129TH ST",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986863324",
            "telephone_number": "360-356-1890"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPACT PHYSICIAN GROUP, WASHINGTON LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-03-04",
        "last_updated": "2022-03-04",
        "certification_date": "2022-03-04",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "PAUL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "678-967-5599",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Vancouver, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 4, 2022; 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.