Provider Demographics
NPI:1548373368
Name:EASTSIDE FAMILY MEDICINE CLINIC
Entity type:Organization
Organization Name:EASTSIDE FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:G
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-453-1039
Mailing Address - Street 1:1200 112TH AVE NE
Mailing Address - Street 2:STE C160
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3732
Mailing Address - Country:US
Mailing Address - Phone:425-453-1039
Mailing Address - Fax:425-453-8955
Practice Address - Street 1:1200 112TH AVE NE
Practice Address - Street 2:STE C160
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3732
Practice Address - Country:US
Practice Address - Phone:425-453-1039
Practice Address - Fax:425-453-8955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7006240Medicaid