Provider Demographics
NPI:1154306884
Name:BLUE MOUNTAIN MEDICAL GOUP, PLLC
Entity Type:Organization
Organization Name:BLUE MOUNTAIN MEDICAL GOUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:STRICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-522-0100
Mailing Address - Street 1:1111 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4118
Mailing Address - Country:US
Mailing Address - Phone:509-522-0100
Mailing Address - Fax:509-527-8010
Practice Address - Street 1:1111 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4118
Practice Address - Country:US
Practice Address - Phone:509-522-0100
Practice Address - Fax:509-527-8010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
WA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Not Answered261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00615Medicaid
OR287665Medicaid
WA7103260Medicaid
WA71121170Medicaid
WA9-2081479Medicare UPIN
OR287665Medicaid
WAAB18460Medicare ID - Type UnspecifiedGROUP NUMBER