1992074066 NPI number — EMERALD CITY SPORTS & SPINE MEDICINE

Table of content: (NPI 1992074066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992074066 NPI number — EMERALD CITY SPORTS & SPINE MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERALD CITY SPORTS & SPINE MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1992074066
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6924 SE ALLEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERCER ISLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98040-3357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-852-8898
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1632 116TH AVE NE
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98004-3035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-818-0558
Provider Business Practice Location Address Fax Number:
888-557-3062
Provider Enumeration Date:
12/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HYMAN
Authorized Official First Name:
GARRETT
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
206-852-8898

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  MD 39116 , 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)





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