Healthcare Provider Details

I. General information

NPI: 1578241139
Provider Name (Legal Business Name): EASTSIDE RHEUMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 112TH AVE NE STE 202
BELLEVUE WA
98004-3759
US

IV. Provider business mailing address

1380 112TH AVE NE STE 202
BELLEVUE WA
98004-3759
US

V. Phone/Fax

Practice location:
  • Phone: 425-590-9521
  • Fax: 425-590-9574
Mailing address:
  • Phone: 425-590-9521
  • Fax: 425-590-9574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: KENT T TA
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 206-240-6423