1639102502 NPI number — DR. JOHN R HIEMSTRA D.O.

Table of content: DR. JOHN R HIEMSTRA D.O. (NPI 1639102502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639102502 NPI number — DR. JOHN R HIEMSTRA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HIEMSTRA
Provider First Name:
JOHN
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1639102502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 W ORCHARD DR
Provider Second Line Business Mailing Address:
SUITE #4
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98225-1766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-318-8800
Provider Business Mailing Address Fax Number:
360-318-1085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1610 GROVER ST
Provider Second Line Business Practice Location Address:
SUITE D-1
Provider Business Practice Location Address City Name:
LYNDEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98264-1539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-354-1333
Provider Business Practice Location Address Fax Number:
360-354-5399
Provider Enumeration Date:
07/07/2006

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:  OP00002028 , 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: 3976HI . This is a "REGENCE BLUESHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00241348 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0199675 . This is a "L&I REGULAR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8431520 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 423898076 . This is a "GROUP HEALTH COOPERATIVE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8906770 . This is a "L&I CRIME VICTIM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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