Healthcare Provider Details

I. General information

NPI: 1689607855
Provider Name (Legal Business Name): NORTHWEST PEDIATRIC OTOLARYNGOLOGY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6850 35TH AVE NE SUITE 4
SEATTLE WA
98115-7344
US

IV. Provider business mailing address

6850 35TH AVE NE STE 4
SEATTLE WA
98115-7344
US

V. Phone/Fax

Practice location:
  • Phone: 206-525-0903
  • Fax: 866-497-3901
Mailing address:
  • Phone: 206-525-0903
  • Fax: 866-497-3901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberMD00039276
License Number StateWA

VIII. Authorized Official

Name: ANIFAT O BALOGUN
Title or Position: OWNER
Credential: MD
Phone: 206-525-0903