Provider Demographics
NPI:1033132956
Name:PUGET SOUND GASTROENTEROLOGY, PLLC
Entity Type:Organization
Organization Name:PUGET SOUND GASTROENTEROLOGY, PLLC
Other - Org Name:PUGET SOUND GASTROENTEROLOGY AT EDMONDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENIO
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-205-3464
Mailing Address - Street 1:PO BOX 34888
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1888
Mailing Address - Country:US
Mailing Address - Phone:425-977-4620
Mailing Address - Fax:425-745-9836
Practice Address - Street 1:21600 HWY 99
Practice Address - Street 2:SUITE 260
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8012
Practice Address - Country:US
Practice Address - Phone:425-774-2650
Practice Address - Fax:425-774-2643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0037140OtherLABOR AND INDUSTRIES
WA1042580Medicaid
WAG8802890Medicare PIN