NPIMap

Organization Active NPI

Mountain West Derm - Blackhart PLLC

Doing business as Advanced Dermatology & Skin Surgery

  • Dermatology Physician
  • Spokane Valley, WA
National Provider Identifier
1013557933
Registry record updated Jan 8, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
MOUNTAIN WEST DERM - BLACKHART PLLC
Doing business as
Advanced Dermatology & Skin Surgery
Practice address
1807 N Hutchinson Rd
Spokane Valley, WA 99212-2444
Phone
(509) 456-7414
Fax
(509) 624-0763
NPI assigned
Jan 8, 2020
Last updated
Jan 8, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 8, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Bret S Blackhart, MDNPI 1992708655
Title
Owner
Phone
(775) 336-3624

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207N00000X Primary
Dermatopathology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207ND0900X
Procedural Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207NS0135X

Addresses

Primary practice location

1807 N Hutchinson Rd
Spokane Valley, WA 99212-2444

Mailing address

1807 N Hutchinson Rd
Spokane Valley, WA 99212-2444
Phone (509) 456-7414

Other practice location 1

1700 W Riverstone Dr
Coeur D Alene, ID 83814-5683
Phone (208) 770-2822

Other practice location 2

5905 N Mayfair St Ste 200
Spokane, WA 99208-1127
Phone (509) 456-7414

Other names 1

  • Advanced Dermatology & Skin Surgery Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID, WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20180808001264 ID Part B Supplier - Clinic/Group Practice 1153609813 Receives reassigned benefits from 29 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Boise, ID; Coeur D Alene, ID
O20200904001722 WA Part B Supplier - Clinic/Group Practice 1153609813 Receives reassigned benefits from 27 practitioners
Practice locations: Spokane, WA; Walla Walla, WA; Spokane Valley, WA

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

3010 S Southeast Blvd
Ste B
Spokane, WA 99223

Practitioners & affiliated clinicians

Practitioners 38

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 38

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1578441600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1578441600000",
    "number": "1013557933",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1807 N HUTCHINSON RD",
            "city": "SPOKANE VALLEY",
            "state": "WA",
            "postal_code": "992122444",
            "telephone_number": "509-456-7414",
            "fax_number": "509-624-0763"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1807 N HUTCHINSON RD",
            "city": "SPOKANE VALLEY",
            "state": "WA",
            "postal_code": "992122444",
            "telephone_number": "509-456-7414",
            "fax_number": "509-624-0763"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1700 W Riverstone Dr",
            "address_purpose": "LOCATION",
            "city": "Coeur D Alene",
            "state": "ID",
            "postal_code": "838145683",
            "country_code": "US",
            "telephone_number": "208-770-2822",
            "fax_number": "208-770-2911",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "5905 N Mayfair St Ste 200",
            "address_purpose": "LOCATION",
            "city": "Spokane",
            "state": "WA",
            "postal_code": "992081127",
            "country_code": "US",
            "telephone_number": "509-456-7414",
            "fax_number": "509-624-0764",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MOUNTAIN WEST DERM - BLACKHART PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-01-08",
        "last_updated": "2020-01-08",
        "certification_date": "2020-01-08",
        "status": "A",
        "authorized_official_last_name": "BLACKHART",
        "authorized_official_first_name": "BRET",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "775-336-3624",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207ND0900X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology, Dermatopathology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology, Procedural Dermatology",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Advanced Dermatology & Skin Surgery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Spokane Valley, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.