Provider Demographics
NPI:1104124247
Name:BELLEVUE OBGYN LLC
Entity type:Organization
Organization Name:BELLEVUE OBGYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:FAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-698-1588
Mailing Address - Street 1:1515 116TH AVE NE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3811
Mailing Address - Country:US
Mailing Address - Phone:425-698-1588
Mailing Address - Fax:
Practice Address - Street 1:1515 116TH AVE NE
Practice Address - Street 2:205
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3811
Practice Address - Country:US
Practice Address - Phone:425-698-1588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-13
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60122545207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty