Provider Demographics
NPI:1528145778
Name:OVERLAKE AMBULATORY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:OVERLAKE AMBULATORY SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-709-7523
Mailing Address - Street 1:1135 116TH AVE NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004
Mailing Address - Country:US
Mailing Address - Phone:425-709-2500
Mailing Address - Fax:425-709-2323
Practice Address - Street 1:1135 116TH AVE NE
Practice Address - Street 2:300
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-709-2500
Practice Address - Fax:425-709-2323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
362OtherPREMERA BLUE CROSS
903004OtherREGENCE BLUE SHIELD
0141317OtherLABOR & INDUSTRIES
WA7102890Medicaid
WAAB17141Medicare ID - Type Unspecified