Provider Demographics
NPI:1992702443
Name:THE EASTSIDE ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:THE EASTSIDE ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GORALSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-383-8342
Mailing Address - Street 1:1135 116TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4623
Mailing Address - Country:US
Mailing Address - Phone:425-544-7684
Mailing Address - Fax:425-462-8021
Practice Address - Street 1:1135 116TH AVE NE
Practice Address - Street 2:SUITE 570
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4623
Practice Address - Country:US
Practice Address - Phone:425-451-7335
Practice Address - Fax:425-451-1226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
15949OtherAAAHC ACCREDITATION
WA50D0923026OtherCLIA NUMBER
WAEA0308OtherREGENCE BS
WAMTS-3102OtherSTATE LICENSE
WA7067366Medicaid
BG4377227OtherDEA LICENSE
15949OtherAAAHC ACCREDITATION
15949OtherAAAHC ACCREDITATION
217000375Medicare PIN