Provider Demographics
NPI:1588603120
Name:MADRONA MEDICAL GROUP, PS
Entity Type:Organization
Organization Name:MADRONA MEDICAL GROUP, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MELLOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-738-2200
Mailing Address - Street 1:4545 CORDATA PKWY
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-7123
Mailing Address - Country:US
Mailing Address - Phone:360-738-2200
Mailing Address - Fax:
Practice Address - Street 1:4545 CORDATA PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7123
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601644971261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA115124400Medicare PIN