Provider Demographics
NPI:1942484399
Name:MERIDIAN MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:MERIDIAN MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMBASIVARAO
Authorized Official - Middle Name:
Authorized Official - Last Name:KARANAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-957-9400
Mailing Address - Street 1:PO BOX 6895
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-0895
Mailing Address - Country:US
Mailing Address - Phone:425-957-9400
Mailing Address - Fax:425-957-9404
Practice Address - Street 1:15921 NE 8TH ST
Practice Address - Street 2:SUITE C 205
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008-3923
Practice Address - Country:US
Practice Address - Phone:425-957-9400
Practice Address - Fax:425-957-9404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8851452Medicare PIN