Provider Demographics
NPI:1801845268
Name:BIRNBAUM, JACK A (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:BIRNBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:360-830-1604
Mailing Address - Fax:
Practice Address - Street 1:2011 NW MYHRE PL
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8561
Practice Address - Country:US
Practice Address - Phone:360-830-1604
Practice Address - Fax:360-830-1695
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029892207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA31818OtherLABOR & INDUSTRY
BI8918OtherREGENCE BLUESHIELD
110055680OtherRAILROAD MEDICARE
4394063OtherAETNA
WA8140972Medicaid
WA8140972Medicaid
WA8140972Medicaid
WAGAB05745Medicare PIN
G000250608Medicare PIN
WA31818OtherLABOR & INDUSTRY
BI8918OtherREGENCE BLUESHIELD
A93037Medicare UPIN
WAG115136403Medicare PIN