Provider Demographics
NPI:1689754673
Name:GEBALLE, ADAM PHILIP
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:PHILIP
Last Name:GEBALLE
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:AMBULATORY CLINIC
Practice Address - Street 2:825 EASTLAKE AVENUE EAST
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109
Practice Address - Country:US
Practice Address - Phone:206-288-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024829207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
3005OtherINTERNAL ID-MOTOR VEHICLE ID
WA8152035Medicaid
F68331Medicare UPIN
107966Medicare ID - Type Unspecified