Provider Demographics
NPI:1518025618
Name:EASTSIDE PREMIER MEDICINE PLLC
Entity Type:Organization
Organization Name:EASTSIDE PREMIER MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:DONLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-284-3377
Mailing Address - Street 1:2950 NORTHUP WAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-1406
Mailing Address - Country:US
Mailing Address - Phone:425-284-3377
Mailing Address - Fax:425-827-1040
Practice Address - Street 1:2950 NORTHUP WAY
Practice Address - Street 2:SUITE 210
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-1406
Practice Address - Country:US
Practice Address - Phone:425-284-3377
Practice Address - Fax:425-827-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2950DOOtherREGENCE
WA2950DOOtherREGENCE
WA8858397Medicare PIN