1053509968 NPI number — DR PAUL A BERGHUIS INC PS

Table of content: (NPI 1053509968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053509968 NPI number — DR PAUL A BERGHUIS INC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR PAUL A BERGHUIS INC PS
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:
Provider Other Organization Name Type Code:
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:
1053509968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98273-0104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-336-6517
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 S LAVENTURE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98274-6033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-336-6517
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MELDAHL
Authorized Official First Name:
CHAR
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING AGENT
Authorized Official Telephone Number:
360-466-2542

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  OP00001383 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: OP00001383 , 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: 2655BE . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1124635 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0226265 . This is a "DEPARTMENT OF LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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