Provider Demographics
NPI:1720392806
Name:PUGET SOUND INSTITUTE OF PATHOLOGY, PLLC
Entity Type:Organization
Organization Name:PUGET SOUND INSTITUTE OF PATHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MECKLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-622-7747
Mailing Address - Street 1:PO BOX 34245
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1245
Mailing Address - Country:US
Mailing Address - Phone:206-622-7747
Mailing Address - Fax:206-467-1470
Practice Address - Street 1:1001 SW KLICKITAT WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134-1161
Practice Address - Country:US
Practice Address - Phone:206-622-7747
Practice Address - Fax:206-467-1470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA50D0633091291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA81407/161839OtherLABOR & INDUSTRIES
WA7066947Medicaid
WA81407/161839OtherLABOR & INDUSTRIES