Provider Demographics
NPI:1649212606
Name:PUGET SOUND GASTROENTEROLOGY, PLLC
Entity Type:Organization
Organization Name:PUGET SOUND GASTROENTEROLOGY, PLLC
Other - Org Name:SEATTLE GASTROENTEROLOGY ASSOCIATES
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 1:11027 MERIDIAN AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-1705
Practice Address - Country:US
Practice Address - Phone:206-365-4492
Practice Address - Fax:206-368-3456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207RG0100X
WA600388519291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1045049Medicaid
WA0031330OtherLABOR AND INDUSTRIES
WA0031330OtherLABOR AND INDUSTRIES