Provider Demographics
NPI:1740367929
Name:FIFTH AVENUE INTERNAL MEDICINE, INC
Entity type:Organization
Organization Name:FIFTH AVENUE INTERNAL MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PALERMO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO, MBA, FACOI
Authorized Official - Phone:206-367-1222
Mailing Address - Street 1:10564 5TH AVE NE STE 201
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-7200
Mailing Address - Country:US
Mailing Address - Phone:206-367-1222
Mailing Address - Fax:206-364-2664
Practice Address - Street 1:10564 5TH AVE NE STE 201
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-7200
Practice Address - Country:US
Practice Address - Phone:206-367-1222
Practice Address - Fax:206-364-2664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP0000836207R00000X
WAAP30005722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7107840Medicaid
WA151558OtherL&I GROUP NUMBER
WAE20232Medicare UPIN
WAGAB22098Medicare PIN
WAAB22098Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER