Provider Demographics
NPI:1558422147
Name:OVERLAKE INTERNAL MEDICINE LABORATORY
Entity Type:Organization
Organization Name:OVERLAKE INTERNAL MEDICINE LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-974-7634
Mailing Address - Street 1:PO BOX 5845
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-5845
Mailing Address - Country:US
Mailing Address - Phone:425-454-5281
Mailing Address - Fax:425-454-2062
Practice Address - Street 1:1407 116TH AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3819
Practice Address - Country:US
Practice Address - Phone:425-454-5046
Practice Address - Fax:425-990-5261
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OVERLAKE INTERNAL MEDICINE ASSOCIATES INC PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-13
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMTS-0111291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB13817Medicare PIN