Provider Demographics
NPI:1467649376
Name:MOUNT BAKER RHEUMATOLOGY CENTER PLLC
Entity Type:Organization
Organization Name:MOUNT BAKER RHEUMATOLOGY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WISNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-676-1610
Mailing Address - Street 1:500 BIRCHWOOD AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1704
Mailing Address - Country:US
Mailing Address - Phone:360-676-1610
Mailing Address - Fax:360-676-2459
Practice Address - Street 1:500 BIRCHWOOD AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1704
Practice Address - Country:US
Practice Address - Phone:360-676-1610
Practice Address - Fax:360-676-2459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA16552207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7138068Medicaid