1497755797 NPI number — DERMATOLOGY & ALLERGY SPECIALISTS

Table of content: (NPI 1497755797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497755797 NPI number — DERMATOLOGY & ALLERGY SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY & ALLERGY SPECIALISTS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DERMATOLOGY & ALLERGY SPECIALISTS OF OLYMPIA
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497755797
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 W BAY DR NW
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98502-4953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-413-8760
Provider Business Mailing Address Fax Number:
360-413-8839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 W BAY DR NW
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98502-4958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-413-8760
Provider Business Practice Location Address Fax Number:
360-413-8839
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BAUER
Authorized Official First Name:
J.
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
360-413-8297

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GAB20350 . This is a "MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7105927 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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