Provider Demographics
NPI:1578711677
Name:SEATTLE SPINE & REHABILITATION MEDICINE PS
Entity Type:Organization
Organization Name:SEATTLE SPINE & REHABILITATION MEDICINE PS
Other - Org Name:SEATTLE SPINE & REHABILITATION MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:SEROUSSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-861-8200
Mailing Address - Street 1:3213 EASTLAKE AVENUE EAST
Mailing Address - Street 2:SUITE A1
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-7127
Mailing Address - Country:US
Mailing Address - Phone:206-861-8200
Mailing Address - Fax:
Practice Address - Street 1:3213 EASTLAKE AVE E
Practice Address - Street 2:SUITE A1
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-7127
Practice Address - Country:US
Practice Address - Phone:206-861-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031281225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB27239Medicare PIN
WAG10592Medicare UPIN