Provider Demographics
NPI:1255728887
Name:BIRCH BAY DERMATOLOGY P.S.
Entity type:Organization
Organization Name:BIRCH BAY DERMATOLOGY P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-255-5049
Mailing Address - Street 1:4540 CORDATA PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-8059
Mailing Address - Country:US
Mailing Address - Phone:360-255-5049
Mailing Address - Fax:360-778-2395
Practice Address - Street 1:4540 CORDATA PKWY
Practice Address - Street 2:STE 101
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-8059
Practice Address - Country:US
Practice Address - Phone:360-255-5049
Practice Address - Fax:360-778-2395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60450667207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH49951Medicare UPIN