Healthcare Provider Details

I. General information

NPI: 1396781373
Provider Name (Legal Business Name): OVERLAKE REPRODUCTIVE HEALTH INC., PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 116TH AVE NE SUITE 640
BELLEVUE WA
98004-4623
US

IV. Provider business mailing address

11232 NE 15TH ST STE 201
BELLEVUE WA
98004-3739
US

V. Phone/Fax

Practice location:
  • Phone: 425-646-4700
  • Fax: 425-646-1076
Mailing address:
  • Phone: 425-646-4700
  • Fax: 425-646-1076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: MATT TYSON
Title or Position: DIRECTOR, MANAGED CARE CONTRACTING
Credential:
Phone: 615-477-6677