Basic Information
Provider Information | |||||||||
NPI: | 1194761155 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERDMAN | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | HARRY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HERDMAN | ||||||||
OtherFirstName: | S | ||||||||
OtherMiddleName: | HARRY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 709 W ORCHARD DR | ||||||||
Address2: | SUITE #4 | ||||||||
City: | BELLINGHAM | ||||||||
State: | WA | ||||||||
PostalCode: | 982251766 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603188800 | ||||||||
FaxNumber: | 3603181085 | ||||||||
Practice Location | |||||||||
Address1: | 3015 SQUALICUM PKWY | ||||||||
Address2: | SUITE 120 | ||||||||
City: | BELLINGHAM | ||||||||
State: | WA | ||||||||
PostalCode: | 982251945 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607337974 | ||||||||
FaxNumber: | 3606762567 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2006 | ||||||||
LastUpdateDate: | 07/24/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00023012 | WA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 423898036 | 01 | WA | GROUP HEALTH COOPERATIVE | OTHER | 8924277 | 01 | WA | LABOR & INDUSTRIES (CV) | OTHER | 1053545 | 05 | WA |   | MEDICAID | 33183 | 01 | WA | REGENCE BLUESHIELD | OTHER | 080145445 | 01 | WA | RAILROAD MEDICARE | OTHER | 0132425 | 01 | WA | LABOR & INDUSTRIES (REG) | OTHER |