Healthcare Provider Details

I. General information

NPI: 1104931039
Provider Name (Legal Business Name): BELLEGROVE OB/GYN, INC. PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 112TH AVE NE STE C115
BELLEVUE WA
98004-3745
US

IV. Provider business mailing address

1200 112TH AVE NE STE C115
BELLEVUE WA
98004-3745
US

V. Phone/Fax

Practice location:
  • Phone: 425-455-0244
  • Fax: 425-455-9411
Mailing address:
  • Phone: 425-455-0244
  • Fax: 425-455-9411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number600249764
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MITCHELL E NUDELMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 425-455-0244