Healthcare Provider Details

I. General information

NPI: 1053509968
Provider Name (Legal Business Name): DR PAUL A BERGHUIS INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S LAVENTURE RD
MOUNT VERNON WA
98274-6033
US

IV. Provider business mailing address

PO BOX 104
MOUNT VERNON WA
98273-0104
US

V. Phone/Fax

Practice location:
  • Phone: 360-336-6517
  • Fax:
Mailing address:
  • Phone: 360-336-6517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOP00001383
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberOP00001383
License Number StateWA

VIII. Authorized Official

Name: CHAR MELDAHL
Title or Position: BILLING AGENT
Credential:
Phone: 360-466-2542