Provider Demographics
NPI:1629055900
Name:COUNTRY DOCTOR COMMUNITY CLINIC
Entity Type:Organization
Organization Name:COUNTRY DOCTOR COMMUNITY CLINIC
Other - Org Name:COUNTRY DOCTOR COMMUNITY HEALTH CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING AND REIMBURSEMENT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:TREPTOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-299-1937
Mailing Address - Street 1:2101 E YESLER WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5959
Mailing Address - Country:US
Mailing Address - Phone:206-299-1937
Mailing Address - Fax:206-299-1920
Practice Address - Street 1:500 19TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-4007
Practice Address - Country:US
Practice Address - Phone:206-299-1600
Practice Address - Fax:206-299-1633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
WA601583685261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8064602Medicaid
WA7034598Medicaid
WA8016438Medicaid
WA7900632Medicaid
WA6013965Medicaid
WA8016081Medicaid
WA16943OtherL&I
WA7034044Medicaid
WA600508852OtherUBI
WA6014948Medicaid
WA7590243Medicaid
WA7034598Medicaid
WAG000148300Medicare PIN