Provider Demographics
NPI:1043690126
Name:BELLINGHAM UROLOGY GROUP, PLLC
Entity type:Organization
Organization Name:BELLINGHAM UROLOGY GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-714-3400
Mailing Address - Street 1:340 BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1782
Mailing Address - Country:US
Mailing Address - Phone:360-714-3400
Mailing Address - Fax:360-714-3402
Practice Address - Street 1:340 BIRCHWOOD AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1782
Practice Address - Country:US
Practice Address - Phone:360-714-3400
Practice Address - Fax:360-714-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603455361261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical