MEDICARE: FAMILY DERMATOLOGY CO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	603137655	OTHER	WA	UBI

General Provider Information

NPI Number	:	1275816910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY DERMATOLOGY CO

Provider Business Mailing Address
First Line	:	275 SE CABOT DR STE A3
Second Line	:
City	:	OAK HARBOR
State	:	WA
Zip	:	98277-3740
Country	:	US
Telephone Number	:	360-682-5024
Fax Number	:	360-682-5749

Provider Business Practice Location Address
First Line	:	275 SE CABOT DR STE A3
Second Line	:
City	:	OAK HARBOR
State	:	WA
Zip	:	98277-3740
Country	:	US
Telephone Number	:	360-682-5024
Fax Number	:	360-682-5749

Authorized Official
Title or Position	:	PRESIDENT
Name	:	REESE BLIEK
Credential	:	PA-C
Telephone Number	:	360-682-5024

Provider Enumeration Date	:	09/20/2011
Last Update Date	:	04/01/2021

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Directions to “FAMILY DERMATOLOGY CO ” Practice Location

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