Basic Information
| Provider Information | |||||||||
| NPI: | 1154306884 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE MOUNTAIN MEDICAL GOUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095220100 | ||||||||
| FaxNumber: | 5095278010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095220100 | ||||||||
| FaxNumber: | 5095278010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | STRICKLER | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5095220100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | X | Ambulatory Health Care Facilities | Clinic/Center | 261QR1300X | WA | X | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 00615 | 05 | OR | MEDICAID | 287665 | 05 | OR | MEDICAID | 7103260 | 05 | WA | MEDICAID | 71121170 | 05 | WA | MEDICAID |