1154302081 NPI number — MICHAEL JAMES POULOS OTR L CHT

Table of content: MICHAEL JAMES POULOS OTR L CHT (NPI 1154302081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154302081 NPI number — MICHAEL JAMES POULOS OTR L CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POULOS
Provider First Name:
MICHAEL
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR L CHT
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:
1154302081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1557
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98227-1557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-676-4263
Provider Business Mailing Address Fax Number:
660-671-3366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1611 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98225-3039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-676-4263
Provider Business Practice Location Address Fax Number:
360-671-3366
Provider Enumeration Date:
11/08/2005

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: 2251H1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5692P0 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0156374 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8935446 . This is a "CRIME VICTIMS LABOR AND I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1960076 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7682388 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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