1063688273 NPI number — OVERLAKE COLON & RECTAL CLINIC, PLLC

Table of content: (NPI 1063688273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063688273 NPI number — OVERLAKE COLON & RECTAL CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OVERLAKE COLON & RECTAL CLINIC, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063688273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 597
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98009-0597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-669-7639
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1135 116TH AVE NE
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98004-4623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-646-7400
Provider Business Practice Location Address Fax Number:
425-646-7449
Provider Enumeration Date:
05/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EHSAN
Authorized Official First Name:
MITRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
206-669-7639

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  MD00039612 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208C00000X , with the licence number: MD00039612 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0159746 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1135EH . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2185705 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1115864 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5810380 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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