Provider Demographics
NPI:1629177225
Name:SPORTS MEDICINE GROUP
Entity Type:Organization
Organization Name:SPORTS MEDICINE GROUP
Other - Org Name:THE SPORTS MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:VADSET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-368-6100
Mailing Address - Street 1:10330 MERIDIAN AVE N
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9451
Mailing Address - Country:US
Mailing Address - Phone:206-368-6100
Mailing Address - Fax:206-368-6101
Practice Address - Street 1:10330 MERIDIAN AVE N
Practice Address - Street 2:SUITE 300
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9451
Practice Address - Country:US
Practice Address - Phone:206-368-6100
Practice Address - Fax:206-368-6101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601 664 888207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1227890001Medicare NSC
WA217119400Medicare ID - Type Unspecified