Basic Information
| Provider Information | |||||||||
| NPI: | 1104974302 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIRGINIA MASON MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VIRGINIA MASON MEDICAL CENTER-PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 9TH AVE | ||||||||
| Address2: | MS:M4-PFS | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065155811 | ||||||||
| FaxNumber: | 2063410274 | ||||||||
| Practice Location | |||||||||
| Address1: | 2671 NE 46TH ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981055041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065258000 | ||||||||
| FaxNumber: | 2065258070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2007 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | GOODRICH | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2062238861 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VIRGINIA MASON MEDICAL CENTER | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7068174 | 05 | WA | MEDICAID |