Provider Demographics
NPI:1669553251
Name:EASTSIDE WOMENS CLINIC
Entity type:Organization
Organization Name:EASTSIDE WOMENS CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZAN
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:WATANABE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:425-899-5600
Mailing Address - Street 1:11919 NE 128TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-7204
Mailing Address - Country:US
Mailing Address - Phone:425-899-5600
Mailing Address - Fax:425-899-5603
Practice Address - Street 1:11919 NE 128TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7204
Practice Address - Country:US
Practice Address - Phone:425-899-5600
Practice Address - Fax:425-899-5603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601368747261QH0100X
WAAP 30000483261QP2300X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9606690Medicaid
WAWA3359OtherREGENCE
WAWA3359OtherREGENCE
WAS67311Medicare PIN
WAG8880129Medicare PIN