Provider Demographics
NPI:1013144617
Name:PROSTATE CANCER CENTER OF SEATTLE, LLC
Entity type:Organization
Organization Name:PROSTATE CANCER CENTER OF SEATTLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:206-328-4215
Mailing Address - Street 1:9730 3RD AVE NE STE 208
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2023
Mailing Address - Country:US
Mailing Address - Phone:206-453-2992
Mailing Address - Fax:
Practice Address - Street 1:9730 3RD AVE NE STE 208
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2023
Practice Address - Country:US
Practice Address - Phone:206-453-2992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6028855122085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8886649Medicare PIN