Individual Professional Information |
|
NPI
|
1356362081
|
|
Unique healthcare provider (clinician) ID assigned by NPPES
|
|
PECOS UID
|
8022132364
|
|
Unique individual clinician ID assigned by PECOS
|
|
Professional Enrollment ID
|
I20100824000462
|
|
Unique ID for the individual professional enrollment that is the source for the data in the observation
|
|
Provider Last Name
|
BELL
|
|
Individual professional last name
|
|
Provider First Name
|
JOHNNY
|
|
Individual professional first name
|
|
Provider Middle Name
|
S
|
|
Individual professional middle name
|
|
Provider Gender
|
M
|
|
The provider's gender if the provider is a person.
|
Medical School Information |
|
Medical School Name
|
UNIVERSITY OF OKLAHOMA COLLEGE OF MEDICINE
|
|
Individual professional's medical school
|
|
Graduation Year
|
1991
|
|
Individual professional's medical school graduation year
|
|
Primary Specialty
|
GENERAL PRACTICE
|
|
Primary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 1
|
FAMILY MEDICINE
|
|
First secondary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 2
|
OSTEOPATHIC MANIPULATIVE MEDICINE
|
|
Second secondary medical specialty reported by the individual professional in the selected enrollment
|
|
All Secondary Specialties
|
FAMILY MEDICINE, OSTEOPATHIC MANIPULATIVE MEDICINE
|
|
All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas
|
Practice Information |
|
Organization Legal Name
|
SHOALWATER BAY TRIBE
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
8820986599
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
2
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
2373 OLD TOKELAND RD BLDG E
|
|
Group Practice or individual's line 1 address
|
|
Line 2 Street Address
|
SHOALWATER BAY TRIBAL CLINIC
|
|
Group Practice or individual's line 2 address
|
|
City
|
TOKELAND
|
|
Group Practice or individual's city
|
|
State
|
WA
|
|
Group Practice or individual's state
|
|
Zip Code
|
985909729
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
3602670119
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
500031
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
GRAYS HARBOR COMMUNITY HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
501303
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
WILLAPA HARBOR HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|