1992702443 NPI number — THE EASTSIDE ENDOSCOPY CENTER LLC

Table of content: (NPI 1992702443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992702443 NPI number — THE EASTSIDE ENDOSCOPY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE EASTSIDE ENDOSCOPY 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:
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:
1992702443
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
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:
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98004-4623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-544-7684
Provider Business Mailing Address Fax Number:
425-462-8021

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 570
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:
425-451-7335
Provider Business Practice Location Address Fax Number:
425-451-1226
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GORALSKY
Authorized Official First Name:
NICOLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
253-383-8342

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: 15949 . This is a "AAAHC ACCREDITATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50D0923026 . This is a "CLIA NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: EA0308 . This is a "REGENCE BS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: MTS-3102 . This is a "STATE LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7067366 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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