Provider Demographics
NPI:1497953921
Name:BLYNN L SHIDELER MD PC
Entity Type:Organization
Organization Name:BLYNN L SHIDELER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BLYNN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHIDELER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-996-1001
Mailing Address - Street 1:1420 NW GILMAN BLVD
Mailing Address - Street 2:SUITE 2 2786
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5394
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 LOWER RAGSDALE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5817
Practice Address - Country:US
Practice Address - Phone:425-996-1001
Practice Address - Fax:206-600-5033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23099208600000X
WAMD00045810208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9670018Medicaid
1265524912OtherNPI FOR INDIVIDUAL
CA00G230990Medicare ID - Type Unspecified
CAZZZ06491ZMedicare UPIN
CAA41852Medicare UPIN