Provider Demographics
NPI:1780737411
Name:RIDDELL, KIM M (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7268
Practice Address - Street 1:310 15TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5103
Practice Address - Country:US
Practice Address - Phone:206-326-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024270207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8132730Medicaid
WAGAB18164Medicare PIN
WAGAB14453Medicare PIN
WAGAB18165Medicare PIN
WA220032073Medicare PIN
WA220032074Medicare PIN
WAGAB18163Medicare PIN
WAG8809581Medicare PIN
WAF02388Medicare UPIN
WAGAB18166Medicare PIN