Provider Demographics
NPI:1992074066
Name:EMERALD CITY SPORTS & SPINE MEDICINE
Entity type:Organization
Organization Name:EMERALD CITY SPORTS & SPINE MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:S
Authorized Official - Last Name:HYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:206-852-8898
Mailing Address - Street 1:6924 SE ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-3357
Mailing Address - Country:US
Mailing Address - Phone:206-852-8898
Mailing Address - Fax:
Practice Address - Street 1:1632 116TH AVE NE
Practice Address - Street 2:STE C
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3035
Practice Address - Country:US
Practice Address - Phone:425-818-0558
Practice Address - Fax:888-557-3062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 39116261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH64720Medicare UPIN