Basic Information
| Provider Information | |||||||||
| NPI: | 1982870796 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THERESA A BURDICK MD LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 801 BROADWAY SUITE 707 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063863605 | ||||||||
| FaxNumber: | 2062549220 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 BROADWAY SUITE 707 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063863605 | ||||||||
| FaxNumber: | 2062549220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2008 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURDICK | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2063683605 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | MD00016175 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VX0000X | MD00016175 | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 1718600 | 05 | WA | MEDICAID |