Provider Demographics
NPI:1356471833
Name:EASTSIDE VASCULAR LLP
Entity Type:Organization
Organization Name:EASTSIDE VASCULAR LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DUDLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORHEAD
Authorized Official - Suffix:II
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:425-450-7007
Mailing Address - Street 1:1135 116TH AVE NE STE 220
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4623
Mailing Address - Country:US
Mailing Address - Phone:425-450-7007
Mailing Address - Fax:425-450-0026
Practice Address - Street 1:1135 116TH AVE NE STE 220
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4623
Practice Address - Country:US
Practice Address - Phone:425-450-7007
Practice Address - Fax:425-450-0026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB3636OtherRAILROAD MEDICARE
WA1371004Medicaid
WA1098326Medicaid
WA1371004Medicaid
WAG16815Medicare PIN
CB3636OtherRAILROAD MEDICARE
WAA05210Medicare UPIN
CB3636Medicare PIN