Basic Information
| Provider Information | |||||||||
| NPI: | 1811091234 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARBORVIEW MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34001 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065981950 | ||||||||
| FaxNumber: | 2065980961 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981042499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065205000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | WALLEY | ||||||||
| AuthorizedOfficialFirstName: | SOMMER | ||||||||
| AuthorizedOfficialMiddleName: | KLEWENO | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 2067443000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HARBORVIEW MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | H-029 | WA | N | Suppliers | Hearing Aid Equipment | 333600000X | H-029 | WA | N | Suppliers | Pharmacy | 3336C0003X | H-029 | WA | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336I0012X | H-029 | WA | N | Suppliers | Pharmacy | Institutional Pharmacy | 335E00000X | H-029 | WA | N | Suppliers | Prosthetic/Orthotic Supplier | 332B00000X | H-029 | WA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1019543 | 05 | WA | MEDICAID | 0013894 | 01 | WA | L&I GROUP PIN | OTHER | 9054602 | 05 | WA | MEDICAID | 49-12463 | 01 | WA | OTHER | OTHER | 8932325 | 05 | WA | MEDICAID | 9054222 | 05 | WA | MEDICAID | 9048018 | 05 | WA | MEDICAID |