Provider Demographics
NPI:1508078320
Name:KIM S. MALLICK, M.D., P.S.
Entity Type:Organization
Organization Name:KIM S. MALLICK, M.D., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:SHANNON
Authorized Official - Last Name:MALLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-215-2323
Mailing Address - Street 1:1221 MADISON ST
Mailing Address - Street 2:SUITE 1218
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1356
Mailing Address - Country:US
Mailing Address - Phone:206-215-2323
Mailing Address - Fax:206-215-2320
Practice Address - Street 1:1221 MADISON ST
Practice Address - Street 2:SUITE 1218
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1356
Practice Address - Country:US
Practice Address - Phone:206-215-2323
Practice Address - Fax:206-215-2320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027008207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1078542Medicaid
WA32114OtherLABOR AND INDUSTRIES
A03651Medicare UPIN