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Mountain West Derm - Blackhart PLLC

Organization Active NPI Dermatology Physician · Spokane Valley, WA

NPI 1013557933 · NPPES record last updated Jan 8, 2020

Key facts

NPI
1013557933
Entity type
Organization (NPI type 2)
Primary specialty
Dermatology Physician 207N00000X
Legal business name
MOUNTAIN WEST DERM - BLACKHART PLLC
Practice address
1807 N Hutchinson Rd
Spokane Valley, WA 99212-2444
Phone
(509) 456-7414
Fax
(509) 624-0763
NPI assigned
Jan 8, 2020
Organization subpart
No

Authorized official

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

Other NPIs on the same Medicare enrollment 1

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

Other NPIs with the same Medicare PAC ID 6

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

Practitioners 116

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 116

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in ID, WA

Medicare enrollment records

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

National Provider Directory

Locations

5905 N Mayfair St
#200
Spokane, WA 99208
Phone 51293039091255

3010 S Southeast Blvd
Ste B
Spokane, WA 99223

1807 N Hutchinson Rd
Spokane Valley, WA 99212
Phone (509) 456-3414

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 207N00000X Yes
Dermatopathology Physician
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 207ND0900X
Procedural Dermatology Physician
Group: 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

  • Advanced Dermatology & Skin Surgery Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jan 8, 2020.

{
    "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

All providers in Spokane Valley, WA · Dermatology Physician in Washington

Sources for this page

Verify at the official NPI Registry.