MEDICARE: ORVILLE KEITH VANDERGRIEND M.D.

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	174400000X	Specialist	10361	WA
2	208600000X	Surgery Physician	MD00010361	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	82107	OTHER	WA	CRIME VICTIMS (PEACEHEALTH)
4	0146VA	OTHER	WA	REGENCE BLUE SHIELD (PEACEHEALTH)

General Provider Information

NPI Number	:	1073662508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ORVILLE KEITH VANDERGRIEND M.D.

Provider Business Mailing Address
First Line	:	3104 SQUALICUM PKWY
Second Line	:	SUITE 101
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-1941
Country	:	US
Telephone Number	:	360-733-2557
Fax Number	:	360-733-4674

Provider Business Practice Location Address
First Line	:	3104 SQUALICUM PKWY
Second Line	:	SUITE 101
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-1941
Country	:	US
Telephone Number	:	360-733-2557
Fax Number	:	360-733-4674

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	01/24/2013

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