Provider Demographics
NPI:1013184621
Name:EASTSIDE PATHOLOGY INC PS
Entity Type:Organization
Organization Name:EASTSIDE PATHOLOGY INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:D
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-646-0922
Mailing Address - Street 1:PO BOX 100559
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-0559
Mailing Address - Country:US
Mailing Address - Phone:843-664-4300
Mailing Address - Fax:843-664-4308
Practice Address - Street 1:1280 116TH AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3803
Practice Address - Country:US
Practice Address - Phone:425-646-0922
Practice Address - Fax:425-646-0925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207ZC0500X, 207ZD0900X, 207ZH0000X, 207ZP0102X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7045651Medicaid