Provider Demographics
NPI:1073663480
Name:DOCTORS CLINIC A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DOCTORS CLINIC A PROFESSIONAL CORPORATION
Other - Org Name:THE DOCTORS CLINIC AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-782-3650
Mailing Address - Street 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:360-782-3650
Mailing Address - Fax:360-782-3686
Practice Address - Street 1:2200 NW MYHRE RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7681
Practice Address - Country:US
Practice Address - Phone:360-830-1100
Practice Address - Fax:360-830-1283
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOCTORS CLINIC A PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-11
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7127996Medicaid
WAP00255455OtherRAILROAD MEDICARE
WA75420OtherLABOR & INDUSTRIES
WA8937973OtherCRIME VICTIMS COMP PROG
WAP00255455OtherRAILROAD MEDICARE