Provider Demographics
NPI:1396199824
Name:SEATTLE EXTRACORPOREAL
Entity Type:Organization
Organization Name:SEATTLE EXTRACORPOREAL
Other - Org Name:VIRGINIA MASON MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PERFUSIONIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CCP
Authorized Official - Phone:206-939-9898
Mailing Address - Street 1:4446 88TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-4148
Mailing Address - Country:US
Mailing Address - Phone:206-939-9898
Mailing Address - Fax:
Practice Address - Street 1:925 SENECA STREET
Practice Address - Street 2:SEATTLE EXTRACORPOREAL
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101
Practice Address - Country:US
Practice Address - Phone:206-223-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA819241282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access