Provider Demographics
NPI:1205196649
Name:MT BAKER SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MT BAKER SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-752-0518
Mailing Address - Street 1:8524 W GAGE BLVD STE A1
Mailing Address - Street 2:BOX 319
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8241
Mailing Address - Country:US
Mailing Address - Phone:509-591-0070
Mailing Address - Fax:
Practice Address - Street 1:4029 NORTHWEST AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9077
Practice Address - Country:US
Practice Address - Phone:360-752-0518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040970261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7144637Medicaid