Basic Information
| Provider Information | |||||||||
| NPI: | 1376742734 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EIJI MINAMI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1135 116TH AVE NE | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980044623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256881916 | ||||||||
| FaxNumber: | 4256881901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1135 116TH AVE NE | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980044623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256881916 | ||||||||
| FaxNumber: | 4256881901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 11/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | MINAMI | ||||||||
| AuthorizedOfficialFirstName: | EIJI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4256881916 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | AM7833266 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1120385 | 05 | WA | MEDICAID | 0064799 | 01 | WA | DEPT OF L&I | OTHER | MI6668 | 01 | WA | REGENCE BLUE SHIELD | OTHER |