Provider Demographics
NPI:1447212337
Name:PUGET SOUND GASTROENTEROLOGY, PLLC
Entity Type:Organization
Organization Name:PUGET SOUND GASTROENTEROLOGY, PLLC
Other - Org Name:EVERGREEN ENDOSCOPY CENTER
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 1:11800 NE 128TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7208
Practice Address - Country:US
Practice Address - Phone:425-899-4500
Practice Address - Fax:425-899-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0155305OtherLABOR AND INDUSTRIES
WA1044235Medicaid
WA0155305OtherLABOR AND INDUSTRIES