Basic Information
| Provider Information | |||||||||
| NPI: | 1932285731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACK | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065436420 | ||||||||
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| Practice Location | |||||||||
| Address1: | AMBULATORY CLINIC | ||||||||
| Address2: | 825 EASTLAKE AVENUE EAST | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062881000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 10/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00022980 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RX0202X | MD00022980 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0002X | MD00022980 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6409 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER | 0230777 | 01 | WA | L&I | OTHER | 1932285731 | 05 | WA | MEDICAID |