1528145778 NPI number — OVERLAKE AMBULATORY SURGERY CENTER, LLC

Table of content: (NPI 1528145778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528145778 NPI number — OVERLAKE AMBULATORY SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OVERLAKE AMBULATORY SURGERY CENTER, LLC
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:
6
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:
1528145778
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1135 116TH AVE NE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-709-2500
Provider Business Mailing Address Fax Number:
425-709-2323

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1135 116TH AVE NE
Provider Second Line Business Practice Location Address:
300
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-709-2500
Provider Business Practice Location Address Fax Number:
425-709-2323
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
425-709-7523

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: 362 . This is a "PREMERA BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 903004 . This is a "REGENCE BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0141317 . This is a "LABOR & INDUSTRIES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7102890 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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