Provider Demographics
NPI:1316421803
Name:R TYLER REIDENBAUGH MD PLLC
Entity type:Organization
Organization Name:R TYLER REIDENBAUGH MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTENDING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:REIDENBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-313-6080
Mailing Address - Street 1:4710 40TH AVE SW STE N408
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4674
Mailing Address - Country:US
Mailing Address - Phone:405-313-6080
Mailing Address - Fax:
Practice Address - Street 1:12101 AMBAUM BLVD SW
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98146-2651
Practice Address - Country:US
Practice Address - Phone:206-244-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-20
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility