Basic Information
| Provider Information | |||||||||
| NPI: | 1881652147 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KITSAP CARDIOLOGY CONSULTANTS, P.L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2709 HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983102623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603732547 | ||||||||
| FaxNumber: | 3604798268 | ||||||||
| Practice Location | |||||||||
| Address1: | 2709 HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983102623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603732547 | ||||||||
| FaxNumber: | 3604798268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BERGLIND | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3603732547 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 7068836 | 05 | WA | MEDICAID |