Provider Demographics
NPI:1093982563
Name:RIEDERER, MARY LUCIE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LUCIE
Last Name:RIEDERER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:M
Other - Middle Name:LUCIE
Other - Last Name:RIEDERER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-738-2200
Mailing Address - Fax:360-752-5282
Practice Address - Street 1:2901 SQUALICUM PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1851
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5282
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027190207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1301910Medicaid
WA0062RIOtherREGENCE
WA1093952563Medicaid
WA0255167OtherL&I AND CRIME VICTIMS
WA9508080OtherAETNA
WA1093952563Medicaid
WAG8889381Medicare PIN