Provider Demographics
NPI:1972539401
Name:OVERLAKE OBSTETRICIANS & GYNECOLOGIST P S
Entity type:Organization
Organization Name:OVERLAKE OBSTETRICIANS & GYNECOLOGIST P S
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:I
Authorized Official - Last Name:PALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-943-3230
Mailing Address - Street 1:1231 116TH AVE NE
Mailing Address - Street 2:SUITE 950
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3804
Mailing Address - Country:US
Mailing Address - Phone:425-454-3366
Mailing Address - Fax:425-460-5954
Practice Address - Street 1:1231 116TH AVE NE
Practice Address - Street 2:SUITE 950
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3804
Practice Address - Country:US
Practice Address - Phone:425-454-3366
Practice Address - Fax:425-460-5954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600035651207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7020803Medicaid
WA7020803Medicaid