Basic Information
| Provider Information | |||||||||
| NPI: | 1992702443 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE EASTSIDE ENDOSCOPY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1135 116TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980044623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255447684 | ||||||||
| FaxNumber: | 4254628021 | ||||||||
| Practice Location | |||||||||
| Address1: | 1135 116TH AVE NE | ||||||||
| Address2: | SUITE 570 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980044623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254517335 | ||||||||
| FaxNumber: | 4254511226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | GORALSKY | ||||||||
| AuthorizedOfficialFirstName: | NICOLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2533838342 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 15949 | 01 | AAAHC ACCREDITATION | OTHER | 50D0923026 | 01 | WA | CLIA NUMBER | OTHER | EA0308 | 01 | WA | REGENCE BS | OTHER | MTS-3102 | 01 | WA | STATE LICENSE | OTHER | 7067366 | 05 | WA | MEDICAID | BG4377227 | 01 | DEA LICENSE | OTHER |