Provider Demographics
NPI:1073662508
Name:VANDERGRIEND, ORVILLE KEITH (MD)
Entity Type:Individual
Prefix:
First Name:ORVILLE
Middle Name:KEITH
Last Name:VANDERGRIEND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 SQUALICUM PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1941
Mailing Address - Country:US
Mailing Address - Phone:360-733-2557
Mailing Address - Fax:360-733-4674
Practice Address - Street 1:3104 SQUALICUM PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1941
Practice Address - Country:US
Practice Address - Phone:360-733-2557
Practice Address - Fax:360-733-4674
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA10361174400000X
WAMD00010361208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1069509Medicaid
WA1073662508Medicaid
WA82107OtherCRIME VICTIMS (PEACEHEALTH)
WA0146VAOtherREGENCE BLUE SHIELD (PEACEHEALTH)
WA1069509Medicaid