Basic Information
| Provider Information | |||||||||
| NPI: | 1396781373 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OVERLAKE REPRODUCTIVE HEALTH INC., PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 84353 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981245653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256464700 | ||||||||
| FaxNumber: | 4256461076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1135 116TH AVE NE | ||||||||
| Address2: | SUITE 640 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980044623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256464700 | ||||||||
| FaxNumber: | 4256461076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 4256464700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8128084 | 05 | WA | MEDICAID |