Provider Demographics
NPI:1760797674
Name:PERGAM MED CORP
Entity Type:Organization
Organization Name:PERGAM MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DORNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-403-6656
Mailing Address - Street 1:2103 HARRISON AVE NW
Mailing Address - Street 2:SUITE 2692
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-2636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2103 HARRISON AVE NW
Practice Address - Street 2:SUITE 2692
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-2636
Practice Address - Country:US
Practice Address - Phone:206-403-6656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031059207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty