1518025618 NPI number — EASTSIDE PREMIER MEDICINE PLLC

Table of content: (NPI 1518025618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518025618 NPI number — EASTSIDE PREMIER MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTSIDE PREMIER MEDICINE 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:
1518025618
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2950 NORTHUP WAY
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98004-1406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-284-3377
Provider Business Mailing Address Fax Number:
425-827-1040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2950 NORTHUP WAY
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98004-1406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-284-3377
Provider Business Practice Location Address Fax Number:
425-827-1040
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DONLAN
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
425-284-3377

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD00032729 , 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: 2950DO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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