Provider Demographics
NPI:1134306111
Name:EASTSIDE REHABILITATION MEDICINE PS
Entity Type:Organization
Organization Name:EASTSIDE REHABILITATION MEDICINE PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:425-392-8513
Mailing Address - Street 1:1128 NE KATSURA ST
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-6919
Mailing Address - Country:US
Mailing Address - Phone:425-392-8513
Mailing Address - Fax:425-392-8521
Practice Address - Street 1:12303 NE 130TH LANE, SUITE 220
Practice Address - Street 2:EVERGREEN HOSPITAL PROFESSIONAL CENTER
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034
Practice Address - Country:US
Practice Address - Phone:425-899-6060
Practice Address - Fax:425-899-6078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041527208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG86194Medicare UPIN