1922104991 NPI number — DR. PENNY ILENE BURDICK MD

Table of content: DR. PENNY ILENE BURDICK MD (NPI 1922104991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922104991 NPI number — DR. PENNY ILENE BURDICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURDICK
Provider First Name:
PENNY
Provider Middle Name:
ILENE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITTEN
Provider Other First Name:
PENNY
Provider Other Middle Name:
ILENE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922104991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 664
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLSBORG
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98324-0664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-461-4538
Provider Business Mailing Address Fax Number:
360-477-4824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
91 BRITTANY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEQUIM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98382-9360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-461-4538
Provider Business Practice Location Address Fax Number:
360-477-4824
Provider Enumeration Date:
09/16/2006

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: 207Q00000X , with the licence number:  MD00024778 , 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: 3296BU . This is a "REGENCE PPN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0245680 . This is a "WA STATE L&I PROVIDER ACCT. #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1127190 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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