Basic Information
| Provider Information | |||||||||
| NPI: | 1407896806 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OVERLAKE INTERNAL MEDICINE ASSOCIATES INC PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5845 | ||||||||
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| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972285845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254545281 | ||||||||
| FaxNumber: | 4259905261 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 116TH AVE NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259905222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | GIANG | ||||||||
| AuthorizedOfficialFirstName: | NGHIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4259747601 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | G217121200 | 01 | WA | MEDICARE | OTHER |