Provider Demographics
NPI:1366610529
Name:PACIFIC HEAD & NECK SURGERY, PLLC
Entity type:Organization
Organization Name:PACIFIC HEAD & NECK SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ LLC MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-467-2747
Mailing Address - Street 1:600 BROADWAY
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5395
Mailing Address - Country:US
Mailing Address - Phone:206-467-2747
Mailing Address - Fax:206-467-1591
Practice Address - Street 1:600 BROADWAY
Practice Address - Street 2:SUITE 260
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5395
Practice Address - Country:US
Practice Address - Phone:206-467-2747
Practice Address - Fax:206-467-1591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014942207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA04265Medicare UPIN
WAGAB19656Medicare PIN