Basic Information
| Provider Information | |||||||||
| NPI: | 1740660513 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE POLYCLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE POLYCLINIC NORTHWEST PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981224201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063291760 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11545 15TH AVE NE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981256358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063642010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2015 | ||||||||
| LastUpdateDate: | 06/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | DAVID | ||||||||
| AuthorizedOfficialFirstName: | LLOYD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2068604401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE POLYCLINIC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.