Provider Demographics
NPI:1184841256
Name:CREEKSIDE SLEEP MEDICINE CENTER PLLC
Entity Type:Organization
Organization Name:CREEKSIDE SLEEP MEDICINE CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-278-2250
Mailing Address - Street 1:1380 112TH AVE NE
Mailing Address - Street 2:#307
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3759
Mailing Address - Country:US
Mailing Address - Phone:425-278-2250
Mailing Address - Fax:425-562-5885
Practice Address - Street 1:1380 112TH AVE NE
Practice Address - Street 2:#307
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3759
Practice Address - Country:US
Practice Address - Phone:425-278-2250
Practice Address - Fax:425-562-5885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207QS1201X
WA602620178261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep MedicineGroup - Single Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602620178OtherUBI
WAG8868739Medicare PIN
WAG8868739Medicare UPIN