Provider Demographics
NPI:1356827828
Name:SEATTLE SPINE GROUP, PLLC
Entity Type:Organization
Organization Name:SEATTLE SPINE GROUP, PLLC
Other - Org Name:SEATTLE REGENERATIVE MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LUCY
Authorized Official - Middle Name:SEIPLE
Authorized Official - Last Name:HOSTETTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-454-0406
Mailing Address - Street 1:1220 116TH AVE NE STE 102
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3826
Mailing Address - Country:US
Mailing Address - Phone:425-454-0406
Mailing Address - Fax:
Practice Address - Street 1:1220 116TH AVE NE STE 102
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-454-0406
Practice Address - Fax:425-454-8225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60174685207L00000X
WAMD00040889207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60174685OtherSTATE MEDICAL LICENSE