Basic Information
| Provider Information | |||||||||
| NPI: | 1013215342 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BELLEVUE PODIATRY INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1370 116TH AVE NE | ||||||||
| Address2: | STE. 206 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254500565 | ||||||||
| FaxNumber: | 4254621742 | ||||||||
| Practice Location | |||||||||
| Address1: | 1370 116TH AVE NE | ||||||||
| Address2: | STE. 206 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254500565 | ||||||||
| FaxNumber: | 4254621742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2011 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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| AuthorizedOfficialLastName: | SAAM | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4254500565 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PO00000789 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1030996 | 05 | WA | MEDICAID |