NPIMap

Individual provider Active NPI

Micah James Roland Mack, DO

  • Internal Medicine Physician
  • Bellevue, WA
National Provider Identifier
1447745450
Registry record updated Nov 16, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
OP61175176 Issued in WA
Practice address
11695 NE 4TH St
Bellevue, WA 98004-5268
Phone
(425) 637-1855
Fax
(206) 344-7970
NPI assigned
Jun 22, 2018
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 16, 2021

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X
Internal Medicine Physician 207R00000X OP61175176 WA Primary

Addresses

Primary practice location

11695 NE 4TH St
Bellevue, WA 98004-5268

Mailing address

11695 NE 4TH St
Bellevue, WA 98004-5268
Phone (425) 637-1855

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20210826003285 WA Practitioner - Internal Medicine 3678978707 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
At Still University of Health Sciences, College of Osteo Med, Kirksville, 2018
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Virginia Mason Medical CenterGroup PAC ID 9830002617, 867 clinicians
Select Outpatient Services IncGroup PAC ID 4082868815, 750 clinicians
Select Rehabilitation, LLCGroup PAC ID 9032020490, 1,935 clinicians

Practice addresses (Care Compare)

11695 NE 4TH St
Bellevue, WA 98004-5268
Phone (425) 637-1855

2600 Compass Rd
Glenview, IL 60026-8001

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

Practice roles

OrganizationSpecialtyStatusNew patients
Virginia Mason Medical Center Internal Medicine CurrentSince Sep 9, 2021 Accepting new patients
Virginia Mason Medical Center Current Accepting new patients
Virginia Mason Medical Center CurrentSince Sep 9, 2021 Accepting new patients
Virginia Mason Medical Center Past Accepting new patients

Locations

380 Winslow Way E
Bainbridge Island, WA 98110
Phone (206) 842-5632

11695 NE 4th St
Bellevue, WA 98004
Phone (425) 637-1855

925 Seneca St
Seattle, WA 98101
Phone (206) 341-0860

4575 Sand Point Way NE
Ste 108
Seattle, WA 98105
Phone (206) 525-8000

Interoperability endpoints

  • FHIR API: https://fhir-myrecord.cerner.com/r4/66ad9a50-d7f7-4c21-b933-2ba90047388e/

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1529625600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1637020800000",
    "number": "1447745450",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11695 NE 4TH ST",
            "city": "BELLEVUE",
            "state": "WA",
            "postal_code": "980045268",
            "telephone_number": "425-637-1855",
            "fax_number": "206-344-7970"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11695 NE 4TH ST",
            "city": "BELLEVUE",
            "state": "WA",
            "postal_code": "980045268",
            "telephone_number": "425-637-1855",
            "fax_number": "206-344-7970"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MACK",
        "first_name": "MICAH",
        "middle_name": "JAMES ROLAND",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-06-22",
        "last_updated": "2021-11-16",
        "certification_date": "2021-11-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "WA",
            "license": "OP61175176",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bellevue, WA

Sources for this page

Verify at the official NPI Registry.