Provider Demographics
NPI:1104931039
Name:BELLEGROVE OB/GYN, INC. PS
Entity type:Organization
Organization Name:BELLEGROVE OB/GYN, INC. PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:NUDELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-455-0244
Mailing Address - Street 1:1200 112TH AVE NE STE C115
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3745
Mailing Address - Country:US
Mailing Address - Phone:425-455-0244
Mailing Address - Fax:425-455-9411
Practice Address - Street 1:1200 112TH AVE NE STE C115
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3745
Practice Address - Country:US
Practice Address - Phone:425-455-0244
Practice Address - Fax:425-455-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600249764261QA1903X
207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty