Basic Information
Provider Information | |||||||||
NPI: | 1982743340 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VIRGINIA MASON MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VIRGINIA MASON FEDERAL WAY SOUTH ASC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 33501 1ST WAY S | ||||||||
Address2: |   | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980036208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538382400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2007 | ||||||||
LastUpdateDate: | 01/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOODRICH | ||||||||
AuthorizedOfficialFirstName: | CRAIG | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2062238861 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VIRGINIA MASON MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | H-010 | WA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | 490005241 | 01 | WA | RAILROAD MC # | OTHER | 7070212 | 05 | WA |   | MEDICAID |