Basic Information
Provider Information | |||||||||
NPI: | 1194801811 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROUDY | ||||||||
FirstName: | VIRGINIA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 50095 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981455095 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2065436420 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | HARBORVIEW MEDICAL CENTER | ||||||||
Address2: | 325 9TH AVE | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 98104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2067313241 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/27/2006 | ||||||||
LastUpdateDate: | 11/22/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZH0000X | MD00022988 | WA | N |   | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207RH0003X | MD00022988 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 7348 | 01 |   | INTERNAL ID-MOTOR VEHICLE ID | OTHER | 830004586 | 01 | WA | RAIL ROAD MEDICARE | OTHER | 1194801811 | 05 | WA |   | MEDICAID |