Basic Information
| Provider Information | |||||||||
| NPI: | 1265763999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WASHINGTON CENTER FOR PAIN MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 827 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980090827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257741538 | ||||||||
| FaxNumber: | 4257745171 | ||||||||
| Practice Location | |||||||||
| Address1: | 21616 76TH AVE W STE 102 | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257741538 | ||||||||
| FaxNumber: | 4257745171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2010 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | HONG | ||||||||
| AuthorizedOfficialFirstName: | HYUN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4257741538 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6229050001 | 01 | WA | DME PTAN | OTHER |