Provider Demographics
NPI:1053509968
Name:DR PAUL A BERGHUIS INC PS
Entity Type:Organization
Organization Name:DR PAUL A BERGHUIS INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MELDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-466-2542
Mailing Address - Street 1:PO BOX 104
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-0104
Mailing Address - Country:US
Mailing Address - Phone:360-336-6517
Mailing Address - Fax:
Practice Address - Street 1:1401 S LAVENTURE RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-6033
Practice Address - Country:US
Practice Address - Phone:360-336-6517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001383207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2655BEOtherREGENCE BLUE SHIELD
WA1124635Medicaid
WA0226265OtherDEPARTMENT OF LABOR AND INDUSTRIES
WA1124635Medicaid
WAG8869620Medicare PIN