Provider Demographics
NPI:1821478686
Name:THE POLYCLINIC
Entity Type:Organization
Organization Name:THE POLYCLINIC
Other - Org Name:THE POLYCLINIC BALLARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-860-4401
Mailing Address - Street 1:1145 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4201
Mailing Address - Country:US
Mailing Address - Phone:206-329-1760
Mailing Address - Fax:
Practice Address - Street 1:1801 NW MARKET ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3987
Practice Address - Country:US
Practice Address - Phone:206-329-1760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE POLYCLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA217115300Medicare PIN