1821107756 NPI number — MARK ALLEN FREEBORN MD

Table of content: MARK ALLEN FREEBORN MD (NPI 1821107756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821107756 NPI number — MARK ALLEN FREEBORN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREEBORN
Provider First Name:
MARK
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821107756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 MADISON STREET
Provider Second Line Business Mailing Address:
SUITE 901
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98104-1172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-264-8100
Provider Business Mailing Address Fax Number:
206-264-8689

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12039 NE 128TH ST STE 500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIRKLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98034-3029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-899-4809
Provider Business Practice Location Address Fax Number:
425-899-4811
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  ML20007796 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0117X , with the licence number: MD60002211 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0251103 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8884369 . This is a "MEDICARE- NON-KING CO." identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8884368 . This is a "MEDICARE KING-CO." identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8884370 . This is a "MEDICARE EMRI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00760994 . This is a "MEDICARE RAILROAD KING CO." identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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