Provider Demographics
NPI:1740238054
Name:SEQUIM PHYSICIAN CLINIC
Entity type:Organization
Organization Name:SEQUIM PHYSICIAN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-683-4181
Mailing Address - Street 1:PO BOX 755
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-0755
Mailing Address - Country:US
Mailing Address - Phone:360-683-4181
Mailing Address - Fax:360-681-3454
Practice Address - Street 1:411 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3343
Practice Address - Country:US
Practice Address - Phone:360-683-4181
Practice Address - Fax:360-681-3454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018876261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP30005395OtherLICENSE GLORIA REDMOND
WAAP30003686OtherLICENSE DIANE ROOT-RACINE
WA7098833Medicaid
WAMD00018876OtherLICENSE ALLEN BERRY
WAAB11968Medicare ID - Type UnspecifiedGROUP NUMBER
WAAP30005395OtherLICENSE GLORIA REDMOND
WAS04394Medicare UPIN
WAA07975Medicare UPIN