Provider Demographics
NPI:1245405950
Name:WASHINGTON OTOLOGY NEUROTOLOGY GROUP, P.S.
Entity type:Organization
Organization Name:WASHINGTON OTOLOGY NEUROTOLOGY GROUP, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:STANFILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-223-0515
Mailing Address - Street 1:901 BOREN AVE
Mailing Address - Street 2:SUITE 711
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3595
Mailing Address - Country:US
Mailing Address - Phone:206-622-6987
Mailing Address - Fax:
Practice Address - Street 1:901 BOREN AVE
Practice Address - Street 2:SUITE 711
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3595
Practice Address - Country:US
Practice Address - Phone:206-622-6987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WASHINGTON OTOLOGY NEUROTOLOGY GROUP, P.S
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-23
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000010422174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1507409Medicaid
WAD33692Medicare UPIN
WA1507409Medicaid