Basic Information
| Provider Information | |||||||||
| NPI: | 1588749758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIDALGO MEDICAL ASSOCIATES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1213 24TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982212592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602933101 | ||||||||
| FaxNumber: | 3605881041 | ||||||||
| Practice Location | |||||||||
| Address1: | 1213 24TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982212592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602933101 | ||||||||
| FaxNumber: | 3605881041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 02/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | CODD | ||||||||
| AuthorizedOfficialFirstName: | PATTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3602995618 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7105711 | 05 | WA | MEDICAID |