=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215093307
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC RETINA SPECIALISTS, PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2006
-----------------------------------------------------
Last Update Date | 02/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1536 N 115TH ST SUITE 300
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98133-8400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-368-5457
-----------------------------------------------------
Fax | 206-368-0622
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 34935 DEPT 66
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98124-1935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-368-5457
-----------------------------------------------------
Fax | 206-368-0622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAY MAX FRIEDMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 206-368-5457
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------