MEDICARE: GH FREMONT ENDOSCOPY CENTER SUB LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1861202137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GH FREMONT ENDOSCOPY CENTER SUB LLC

Provider Business Mailing Address
First Line	:	501 N 34TH ST STE 101
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-8856
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 N 34TH ST STE 101
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-8856
Country	:	US
Telephone Number	:	469-872-4706
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	ERIC BOON
Credential	:
Telephone Number	:	480-567-0269

Provider Enumeration Date	:	01/09/2025
Last Update Date	:	01/09/2025

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