Provider Demographics
NPI:1679659478
Name:ELLENBOGEN, RICHARD G
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:ELLENBOGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HARBORVIEW MEDICAL CENTER
Practice Address - Street 2:PBS BUILDING 401 BROADWAY
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122
Practice Address - Country:US
Practice Address - Phone:206-744-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035342207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8212821Medicaid
227960OtherINTERNAL ID-MOTOR VEHICLE ID
227960OtherINTERNAL ID-MOTOR VEHICLE ID
E98848Medicare UPIN