Basic Information
| Provider Information | |||||||||
| NPI: | 1871863605 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIRGINIA MASON MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANDPOINT PEDIATRICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 4575 SAND POINT WAY NE | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981053950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065258000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2012 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | GOODRICH | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2062238861 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | AP60254262 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.