Basic Information
| Provider Information | |||||||||
| NPI: | 1073663480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCTORS CLINIC A PROFESSIONAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE DOCTORS CLINIC AMBULATORY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9621 RIDGETOP BLVD NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607823650 | ||||||||
| FaxNumber: | 3607823686 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 NW MYHRE RD | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983837681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608301100 | ||||||||
| FaxNumber: | 3608301283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 05/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | BURGHART | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3607823650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DOCTORS CLINIC A PROFESSIONAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | N | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 7127996 | 05 | WA | MEDICAID | P00255455 | 01 | WA | RAILROAD MEDICARE | OTHER | 75420 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8937973 | 01 | WA | CRIME VICTIMS COMP PROG | OTHER |