Provider Demographics
NPI:1700833357
Name:THE DOCTORS CLINIC A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:THE DOCTORS CLINIC A PROFESSIONAL CORPORATION
Other - Org Name:THE DOCTORS CLINIC SALMON MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-782-3600
Mailing Address - Street 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 NW MYHRE RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7681
Practice Address - Country:US
Practice Address - Phone:360-830-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8903693OtherCRIME VICTIMS COMP
WA7127822OtherLABOR & INDUSTRY P.T.
WA7126790Medicaid
11945OtherCLIA
WA75420OtherLABOR & INDUSTRIES
WACU0247OtherRAILROAD MEDICARE
337018607OtherOWCP
11945OtherCLIA
WAG8851512Medicare PIN