Provider Demographics
NPI:1457532004
Name:BELLINGHAM MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:BELLINGHAM MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KRUMDIACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-715-9500
Mailing Address - Street 1:4204 MERIDIAN ST, STE 105
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226
Mailing Address - Country:US
Mailing Address - Phone:360-715-9500
Mailing Address - Fax:360-752-1407
Practice Address - Street 1:4204 MERIDIAN ST, STE 105
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226
Practice Address - Country:US
Practice Address - Phone:360-715-9500
Practice Address - Fax:360-752-1407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2011-03-25
Deactivation Date:2011-02-22
Deactivation Code:
Reactivation Date:2011-03-21
Provider Licenses
StateLicense IDTaxonomies
WAMD00039703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8802019Medicare PIN
WAH05057Medicare UPIN