Basic Information
| Provider Information | |||||||||
| NPI: | 1073602991 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MADRONA MEDICAL GROUP,PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4545 CORDATA PKWY | ||||||||
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| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982267123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607382200 | ||||||||
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| Address1: | 4545 CORDATA PKWY | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982267123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607382200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 03/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | MELLOTT | ||||||||
| AuthorizedOfficialFirstName: | SANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR CLINICAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3607382200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.