Provider Demographics
NPI:1386968329
Name:BILDERBACK, PHILLIP ANDREW (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ANDREW
Last Name:BILDERBACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 N 13TH LOOP RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2166
Mailing Address - Country:US
Mailing Address - Phone:360-427-9549
Mailing Address - Fax:
Practice Address - Street 1:1710 N 13TH LOOP RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2166
Practice Address - Country:US
Practice Address - Phone:360-427-9549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60668454208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO701000331Medicare UPIN
MO1386968329Medicaid