=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083817936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE PULMONARY ASSOCIATES INC PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 01/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 919 109TH AVE NE
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-4485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-646-3993
-----------------------------------------------------
Fax | 425-453-8274
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 88
-----------------------------------------------------
City | RONALD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98940-0088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-761-6401
-----------------------------------------------------
Fax | 509-674-6896
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. BARRY LYON MARMORSTEIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 425-761-6401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | MD00013991
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------