Provider Demographics
NPI:1235398363
Name:BLUE MOUNTAIN MEDICAL INC
Entity Type:Organization
Organization Name:BLUE MOUNTAIN MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:TALL
Authorized Official - Suffix:
Authorized Official - Credentials:RRT RPSGT
Authorized Official - Phone:425-673-3774
Mailing Address - Street 1:7320 216TH ST SW
Mailing Address - Street 2:SUITE #30
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8006
Mailing Address - Country:US
Mailing Address - Phone:425-673-3773
Mailing Address - Fax:425-673-3776
Practice Address - Street 1:17700 SE 272ND ST
Practice Address - Street 2:SUITE #350
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4951
Practice Address - Country:US
Practice Address - Phone:253-372-7325
Practice Address - Fax:253-372-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALR00000073332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA995195Medicaid
WA4990360002Medicare NSC