Basic Information
| Provider Information | |||||||||
| NPI: | 1649212606 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUGET SOUND GASTROENTEROLOGY, PLLC | ||||||||
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| OtherOrganizationName: | SEATTLE GASTROENTEROLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34888 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259774620 | ||||||||
| FaxNumber: | 4257459836 | ||||||||
| Practice Location | |||||||||
| Address1: | 11027 MERIDIAN AVE N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981331705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063654492 | ||||||||
| FaxNumber: | 2063683456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | EUGENIO | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7862053464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 600388519 | WA | N | Laboratories | Clinical Medical Laboratory | 207RG0100X | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1045049 | 05 | WA | MEDICAID | 0031330 | 01 | WA | LABOR AND INDUSTRIES | OTHER |