Provider Demographics
NPI:1679757405
Name:EASTSIDE MEDICINE PS
Entity Type:Organization
Organization Name:EASTSIDE MEDICINE PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEPE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:425-318-4848
Mailing Address - Street 1:18920 BOTHELL WAY NE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-1981
Mailing Address - Country:US
Mailing Address - Phone:425-318-4848
Mailing Address - Fax:786-975-2643
Practice Address - Street 1:18920 BOTHELL WAY NE
Practice Address - Street 2:SUITE 203
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-1981
Practice Address - Country:US
Practice Address - Phone:425-318-4848
Practice Address - Fax:786-975-2643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8120255Medicaid
WA8866139Medicare PIN