Provider Demographics
NPI:1497152631
Name:BELLINGHAM UROLOGY GROUP PLLC
Entity Type:Organization
Organization Name:BELLINGHAM UROLOGY GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-714-3400
Mailing Address - Street 1:340 BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1782
Mailing Address - Country:US
Mailing Address - Phone:360-714-3400
Mailing Address - Fax:360-714-3402
Practice Address - Street 1:340 BIRCHWOOD AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:360-647-1601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024911208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty