Healthcare Provider Details

I. General information

NPI: 1114238615
Provider Name (Legal Business Name): STEPHEN GINGRICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 12TH AVE S
SEATTLE WA
98144-2712
US

IV. Provider business mailing address

1200 12TH AVE S
SEATTLE WA
98144-2712
US

V. Phone/Fax

Practice location:
  • Phone: 206-505-1001
  • Fax:
Mailing address:
  • Phone: 206-505-1001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD60575995
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: