Basic Information
| Provider Information | |||||||||
| NPI: | 1205196649 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MT BAKER SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8524 W GAGE BLVD STE A1 | ||||||||
| Address2: | BOX 319 | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993368241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095910070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4029 NORTHWEST AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982269077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607520518 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2012 | ||||||||
| LastUpdateDate: | 05/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3607520518 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | MD00040970 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 7144637 | 05 | WA | MEDICAID |