Basic Information
| Provider Information | |||||||||
| NPI: | 1558422147 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OVERLAKE INTERNAL MEDICINE LABORATORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5845 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972285845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254545281 | ||||||||
| FaxNumber: | 4254542062 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 116TH AVE NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254545046 | ||||||||
| FaxNumber: | 4259905261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | SCHUBERT | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4259747634 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OVERLAKE INTERNAL MEDICINE ASSOCIATES INC PS | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | MTS-0111 | WA | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.