Provider Demographics
NPI:1689607855
Name:NORTHWEST PEDIATRIC OTOLARYNGOLOGY GROUP
Entity Type:Organization
Organization Name:NORTHWEST PEDIATRIC OTOLARYNGOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANIFAT
Authorized Official - Middle Name:O
Authorized Official - Last Name:BALOGUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-525-0903
Mailing Address - Street 1:6850 35TH AVE NE
Mailing Address - Street 2:STE 4
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-7344
Mailing Address - Country:US
Mailing Address - Phone:206-525-0903
Mailing Address - Fax:866-497-3901
Practice Address - Street 1:6850 35TH AVE NE
Practice Address - Street 2:SUITE 4
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-7344
Practice Address - Country:US
Practice Address - Phone:206-525-0903
Practice Address - Fax:866-497-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039276207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
61-1494589OtherTAX ID (EIN)
61-1494589OtherTAX ID (EIN)
61-1494589OtherTAX ID (EIN)