Provider Demographics
NPI:1902645013
Name:PROMED PREFERRED WA PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PROMED PREFERRED WA PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEV
Authorized Official - Middle Name:
Authorized Official - Last Name:GRINMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-285-8746
Mailing Address - Street 1:4 LEGENDS CIR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16400 SOUTHCENTER PKWY STE 309
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-3302
Practice Address - Country:US
Practice Address - Phone:425-285-8746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-20
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty