Provider Demographics
NPI:1710161260
Name:KUTSYS MEDICAL PRACTICE INCORPORATED
Entity Type:Organization
Organization Name:KUTSYS MEDICAL PRACTICE INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-637-2340
Mailing Address - Street 1:1750 112TH AVE NE
Mailing Address - Street 2:STE D160
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3752
Mailing Address - Country:US
Mailing Address - Phone:425-637-2340
Mailing Address - Fax:425-637-0036
Practice Address - Street 1:1545 116TH AVE NE STE 104
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3813
Practice Address - Country:US
Practice Address - Phone:425-637-2340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032596207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG19950Medicare UPIN
WAG8807713Medicare PIN