Provider Demographics
NPI:1750709358
Name:EASTSIDE MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:EASTSIDE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-837-9720
Mailing Address - Street 1:1301 4TH AVE NW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-9371
Mailing Address - Country:US
Mailing Address - Phone:425-270-3713
Mailing Address - Fax:425-295-7557
Practice Address - Street 1:1301 4TH AVE NW
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-9371
Practice Address - Country:US
Practice Address - Phone:425-270-3713
Practice Address - Fax:425-295-7557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty