Basic Information
| Provider Information | |||||||||
| NPI: | 1801828421 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OVERLAKE MEDICAL CLINICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3947 | ||||||||
| Address2: | MS 315010 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981243947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256885670 | ||||||||
| FaxNumber: | 4256885139 | ||||||||
| Practice Location | |||||||||
| Address1: | 1135 116TH AVE NE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256885670 | ||||||||
| FaxNumber: | 4256885124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 10/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | SCHULTZ | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4256885470 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 7102015 | 05 | WA | MEDICAID |