1992702443 NPI number — THE EASTSIDE ENDOSCOPY CENTER LLC

Table of Contents

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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