Provider Demographics
NPI:1750369211
Name:VANDERHEIDEN, SCOTT MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:VANDERHEIDEN
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 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000434312085R0202X
IDM-123202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA204123OtherL & I PROVIDER NUMBER
WA184155OtherL&I PROVIDER NUMBER
ID1750369211Medicaid
WA184156OtherL&I PROVIDER NUMBER
WA184154OtherL&I PROVIDER NUMBER
ID20004619Medicaid
WA8390452Medicaid
ID20004619Medicaid
WAP00368484Medicare PIN
WAH22328Medicare UPIN
WAG8802680Medicare PIN
WAG8879733Medicare PIN
WAG8803110Medicare PIN
WAP00785790Medicare PIN
WA184156OtherL&I PROVIDER NUMBER
WAP00302168Medicare PIN
WAP00139125Medicare PIN
WAG8857906Medicare PIN