Provider Demographics
NPI:1326090721
Name:NORTHWEST SPINE & SPORTS PHYSICIANS
Entity Type:Organization
Organization Name:NORTHWEST SPINE & SPORTS PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL STAFF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:452-451-2272
Mailing Address - Street 1:1750 112TH AVE NE
Mailing Address - Street 2:STE D-258
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3752
Mailing Address - Country:US
Mailing Address - Phone:425-451-2272
Mailing Address - Fax:452-451-1052
Practice Address - Street 1:1750 112TH AVE NE
Practice Address - Street 2:STE D-258
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3752
Practice Address - Country:US
Practice Address - Phone:425-451-2272
Practice Address - Fax:452-451-1052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033845208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB09758Medicare ID - Type Unspecified