Healthcare Provider Details

I. General information

NPI: 1013184621
Provider Name (Legal Business Name): EASTSIDE PATHOLOGY INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 116TH AVE NE SUITE 100
BELLEVUE WA
98004-3803
US

IV. Provider business mailing address

PO BOX 100559
FLORENCE SC
29502-0559
US

V. Phone/Fax

Practice location:
  • Phone: 425-646-0922
  • Fax: 425-646-0925
Mailing address:
  • Phone: 843-664-4300
  • Fax: 843-664-4308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateWA

VIII. Authorized Official

Name: DR. BRENT D BENJAMIN
Title or Position: PRESIDENT
Credential: MD
Phone: 425-646-0922