MEDICARE: SEATTLE SPINE & REHABILITATION MEDICINE PS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner	MD00031281	WA

General Provider Information

NPI Number	:	1578711677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEATTLE SPINE & REHABILITATION MEDICINE PS

Provider Business Mailing Address
First Line	:	3213 EASTLAKE AVENUE EAST
Second Line	:	SUITE A1
City	:	SEATTLE
State	:	WA
Zip	:	98102-7127
Country	:	US
Telephone Number	:	206-861-8200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3213 EASTLAKE AVE E
Second Line	:	SUITE A1
City	:	SEATTLE
State	:	WA
Zip	:	98102-7127
Country	:	US
Telephone Number	:	206-861-8200
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	RICHARD E SEROUSSI
Credential	:	M.D.
Telephone Number	:	206-861-8200

Provider Enumeration Date	:	09/03/2008
Last Update Date	:	12/14/2010

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