1023092392 NPI number — MARLENE I BRIDGFORTH ARNP

Table of content: MARLENE I BRIDGFORTH ARNP (NPI 1023092392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023092392 NPI number — MARLENE I BRIDGFORTH ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRIDGFORTH
Provider First Name:
MARLENE
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MIUS
Provider Other First Name:
MARLENE
Provider Other Middle Name:
I
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023092392
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 S CEDAR ST
Provider Second Line Business Mailing Address:
#301 CARDIAC STUDY CENTER INC PS
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-2308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-572-7320
Provider Business Mailing Address Fax Number:
253-627-3191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 S CEDAR ST
Provider Second Line Business Practice Location Address:
#301 CARDIAC STUDY CENTER INC PS
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-2308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-572-7320
Provider Business Practice Location Address Fax Number:
253-627-3191
Provider Enumeration Date:
12/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  AP30004776 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9622390 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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