1811914625 NPI number — PUGET SOUND GASTROENTEROLOGY, PLLC

Table of content: (NPI 1811914625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811914625 NPI number — PUGET SOUND GASTROENTEROLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUGET SOUND GASTROENTEROLOGY, 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:
EDMONDS ENDOSCOPY CENTER
Provider Other Organization Name Type Code:
3
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:
1811914625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 34888
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-1888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-977-4620
Provider Business Mailing Address Fax Number:
425-745-9836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21600 HWY 99
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98026-8012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-774-2650
Provider Business Practice Location Address Fax Number:
425-774-2643
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
EUGENIO
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
786-205-3464

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8906971 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1045755 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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