Provider Demographics
NPI:1740408293
Name:METROLIANCE FOOT AND ANKLE GROUP
Entity Type:Organization
Organization Name:METROLIANCE FOOT AND ANKLE GROUP
Other - Org Name:EASTSIDE PODIATRY ASC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAE SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:425-893-8100
Mailing Address - Street 1:2950 NORTHUP WAY
Mailing Address - Street 2:SUITE 115
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-1406
Mailing Address - Country:US
Mailing Address - Phone:425-893-8100
Mailing Address - Fax:
Practice Address - Street 1:2950 NORTHUP WAY
Practice Address - Street 2:SUITE 115
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-1406
Practice Address - Country:US
Practice Address - Phone:425-893-8100
Practice Address - Fax:425-893-8111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA301261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA217000039Medicare ID - Type Unspecified