Provider Demographics
NPI:1902043284
Name:AESTHETIC & GENERAL DERMATOLOGY OF SEATTLE
Entity Type:Organization
Organization Name:AESTHETIC & GENERAL DERMATOLOGY OF SEATTLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-248-5020
Mailing Address - Street 1:13610 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98168-3404
Mailing Address - Country:US
Mailing Address - Phone:206-245-8502
Mailing Address - Fax:206-244-8425
Practice Address - Street 1:13610 1ST AVE S
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98168-3404
Practice Address - Country:US
Practice Address - Phone:206-245-8502
Practice Address - Fax:206-244-8425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7089576Medicaid
WA8804523Medicare PIN