1316988926 NPI number — DR. BRUCE M PEDERSON MD

Table of content: DR. BRUCE M PEDERSON MD (NPI 1316988926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316988926 NPI number — DR. BRUCE M PEDERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDERSON
Provider First Name:
BRUCE
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316988926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 W ORCHARD DR
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98225-1766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-318-8800
Provider Business Mailing Address Fax Number:
360-318-1085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8097 HARBORVIEW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLAINE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98230-9639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-371-5855
Provider Business Practice Location Address Fax Number:
360-371-5857
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD00014727 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 080147969 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 423898002 . This is a "GROUP HEALTH COOPERATIVE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8924735 . This is a "LABOR & INDUSTRIES (CV)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1722602 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14509 . This is a "REGENCE BLUESHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0128920 . This is a "LABOR & INDUSTRIES (REG)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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