MEDICARE: J SEMMES MICKELWAIT MD PS

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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1114950375
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J SEMMES MICKELWAIT MD PS

Provider Business Mailing Address
First Line	:	1420 ROOSEVELT AVE
Second Line	:	SUITE 7
City	:	MOUNT VERNON
State	:	WA
Zip	:	98273-2687
Country	:	US
Telephone Number	:	360-424-4186
Fax Number	:	360-428-0927

Provider Business Practice Location Address
First Line	:	1420 ROOSEVELT AVE
Second Line	:	SUITE 7
City	:	MOUNT VERNON
State	:	WA
Zip	:	98273-2687
Country	:	US
Telephone Number	:	360-424-4186
Fax Number	:	360-428-0927

Authorized Official
Title or Position	:	OWNER
Name	:	J SEMMES MICKELWAIT
Credential	:	MD
Telephone Number	:	360-424-4186

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	08/22/2020

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