Provider Demographics
NPI:1619998978
Name:INTERLAKE MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:INTERLAKE MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:LEOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-746-2400
Mailing Address - Street 1:2103 152ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-5520
Mailing Address - Country:US
Mailing Address - Phone:425-746-2400
Mailing Address - Fax:425-746-2659
Practice Address - Street 1:2103 152ND AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5520
Practice Address - Country:US
Practice Address - Phone:425-746-2400
Practice Address - Fax:425-746-2659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB34694Medicare ID - Type Unspecified