Provider Demographics
NPI:1790057792
Name:ANACORTES DERMATOLOGY PC INC
Entity Type:Organization
Organization Name:ANACORTES DERMATOLOGY PC INC
Other - Org Name:ANACORTES DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WIRT
Authorized Official - Middle Name:ANDERSON
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-395-8768
Mailing Address - Street 1:1801 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221
Mailing Address - Country:US
Mailing Address - Phone:360-399-6036
Mailing Address - Fax:360-588-1691
Practice Address - Street 1:1801 COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221
Practice Address - Country:US
Practice Address - Phone:360-399-6036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X, 207NP0225X, 207NS0135X
WAMD00045767261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty