=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265524912
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLYNN L SHIDELER M.D., P.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 576 HARTNELL ST SUITE 200
-----------------------------------------------------
City | MONTEREY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93940-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-996-1001
-----------------------------------------------------
Fax | 206-600-5033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1420 NW GILMAN BLVD SUITE 2-2786
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-5394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-996-1001
-----------------------------------------------------
Fax | 206-600-5033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | G23099
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MD00045810
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------