Basic Information
| Provider Information | |||||||||
| NPI: | 1003852500 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY CARE NETWORK PLLC | ||||||||
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| OtherOrganizationName: | FAMILY CARE NETWORK MEDICAL TESTING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 709 W ORCHARD DRIVE | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982250066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603188800 | ||||||||
| FaxNumber: | 3603181085 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 SQUALICUM PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607560382 | ||||||||
| FaxNumber: | 3607565184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | HIPSKIND | ||||||||
| AuthorizedOfficialFirstName: | MARCY | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | FAMILY CARE NETWORK PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3603188800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY CARE NETWORK PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 192942513 | 01 | WA | US DEPT OF LABOR CLINIC NUMBER | OTHER |