NPIMap

Organization Active NPI

Mountain West Derm - Blackhart PLLC

Doing business as Bend Dermatology Clinic

  • Dermatology Physician
  • Bend, OR
National Provider Identifier
1447764741
Registry record updated Nov 22, 2017
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
Bend Dermatology Clinic
Practice address
2747 NE Conners Ave
Bend, OR 97701-8738
Phone
(541) 382-5712
NPI assigned
Nov 22, 2017
Last updated
Nov 22, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 22, 2017

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
MD
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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

2747 NE Conners Ave
Bend, OR 97701-8738

Mailing address

640 W Moana LN
Reno, NV 89509-4903
Phone (775) 324-0699

Other names 1

  • Bend Dermatology Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20171219002516 OR Part B Supplier - Clinic/Group Practice 1153609813 Receives reassigned benefits from 39 practitioners
2 other NPIs on this enrollment
Practice locations: Tigard, OR; Roseburg, OR; Redmond, OR; Bend, OR; Prineville, OR; Klamath Falls, OR; Lake Oswego, OR; Ashland, OR

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 2

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

National Provider Directory

National Provider Directory

Locations

3950 Gs Richards Blvd
Carson City, NV 89703
Phone (775) 283-4080

2855 NW Crossing Dr
Ste 104
Bend, OR 97703

111 NW Larch Ave
Redmond, OR 97756
Phone (541) 923-4462

Practitioners & affiliated clinicians

Practitioners 40

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 40

NPI Registry JSON

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

{
    "created_epoch": "1511308800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1511308800000",
    "number": "1447764741",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "640 W MOANA LN",
            "city": "RENO",
            "state": "NV",
            "postal_code": "895094903",
            "telephone_number": "775-324-0699"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2747 NE CONNERS AVE",
            "city": "BEND",
            "state": "OR",
            "postal_code": "977018738",
            "telephone_number": "541-382-5712"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN WEST DERM - BLACKHART PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-11-22",
        "last_updated": "2017-11-22",
        "status": "A",
        "authorized_official_last_name": "BLACKHART",
        "authorized_official_first_name": "BRET",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "MD",
        "authorized_official_telephone_number": "775-336-3624",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Bend Dermatology Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bend, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2017; 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.