Basic Information
| Provider Information | |||||||||
| NPI: | 1134511686 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIRGINIA MASON MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VM SLEEP DURABLE MEDICAL EQUIPMENT SUPPLIES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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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: | 1100 9TH AVE | ||||||||
| Address2: | MS-H10SLP | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066257180 | ||||||||
| FaxNumber: | 2033410447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2015 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOODRICH | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2062238861 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VIRGINIA MASON MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | H-010 | WA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.