1063473841 NPI number — DR. WM JOHN BULLIS MD

Table of content: DR. WM JOHN BULLIS MD (NPI 1063473841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063473841 NPI number — DR. WM JOHN BULLIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BULLIS
Provider First Name:
WM
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1063473841
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8610 NE 17TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLYDE HILL
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98004-3241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-720-0691
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8610 NE 17TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLYDE HILL
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98004-3241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-720-0691
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2006

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: 207VG0400X , with the licence number:  60033065 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207VG0400X , with the licence number: M-10613 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 86806 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".
  • Identifier: FH1000860 . This is a "FIRST CAROLINA CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8911941 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: N0044A , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9663436 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 160051634 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11941 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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