Provider Demographics
NPI:1992878763
Name:NORTHWEST SPINE & SPORTS PHYSICIANS
Entity type:Organization
Organization Name:NORTHWEST SPINE & SPORTS PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-451-2272
Mailing Address - Street 1:1750 112TH AVE NE
Mailing Address - Street 2:SUITE D 258
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3752
Mailing Address - Country:US
Mailing Address - Phone:425-451-2272
Mailing Address - Fax:425-451-1052
Practice Address - Street 1:1750 112TH AVE NE
Practice Address - Street 2:SUITE D 258
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3752
Practice Address - Country:US
Practice Address - Phone:425-451-2272
Practice Address - Fax:425-451-1052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601873433208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty