Basic Information
| Provider Information | |||||||||
| NPI: | 1548350713 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KING COUNTY PUBLIC HOSPITAL DISTRICT NO 2 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SENIOR HEALTH SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 34036 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258993292 | ||||||||
| FaxNumber: | 4258993269 | ||||||||
| Practice Location | |||||||||
| Address1: | 11521 NE 128TH ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980344317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258996800 | ||||||||
| FaxNumber: | 4258996808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MYCROFT | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTINE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4258992606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KING COUNTY PUBLIC HOSPITAL DISTRICT NO 2 | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CG8137 | 01 | WA | MEDICARE RAILROAD | OTHER | CJ9678 | 01 | WA | MEDICARE RAILROAD | OTHER | 7114184 | 05 | WA | MEDICAID | CG2833 | 01 | WA | MEDICARE RAILROAD | OTHER | CQ2437 | 01 | WA | MEDICARE RAILROAD | OTHER |