Provider Demographics
NPI:1679649248
Name:BLUE MOUNTAIN FAMILY HEALTH PLLC
Entity Type:Organization
Organization Name:BLUE MOUNTAIN FAMILY HEALTH PLLC
Other - Org Name:BLUE MOUNTAIN FAMILY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-751-5500
Mailing Address - Street 1:1271 HIGHLAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2846
Mailing Address - Country:US
Mailing Address - Phone:509-751-5500
Mailing Address - Fax:509-751-1059
Practice Address - Street 1:1271 HIGHLAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2846
Practice Address - Country:US
Practice Address - Phone:509-751-5500
Practice Address - Fax:509-751-1059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80745000Medicaid
WA7130354Medicaid
ID807278700Medicaid
WA8439333Medicaid
8856302Medicare PIN
ID807278700Medicaid
WA8439333Medicaid