Provider Demographics
NPI:1922131762
Name:EVERETT UROLOGICAL, PLLC.
Entity Type:Organization
Organization Name:EVERETT UROLOGICAL, PLLC.
Other - Org Name:EVERETT UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:DAN
Authorized Official - Last Name:BARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-252-2313
Mailing Address - Street 1:4225 HOYT AVE STE C
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2351
Mailing Address - Country:US
Mailing Address - Phone:425-252-2313
Mailing Address - Fax:
Practice Address - Street 1:4225 HOYT AVE STE C
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2351
Practice Address - Country:US
Practice Address - Phone:425-252-2313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWH20734261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1027812Medicaid
WAAB39659Medicare ID - Type Unspecified
WA1027812Medicaid