MEDICARE: SAMMAMISH DIABETES AND LIPID CLINIC, PLLC

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	261Q00000X	Clinic/Center		WA

General Provider Information

NPI Number	:	1578743290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMMAMISH DIABETES AND LIPID CLINIC, PLLC

Provider Business Mailing Address
First Line	:	3854 E LAKE SAMMAMISH PKWY NE
Second Line	:
City	:	SAMMAMISH
State	:	WA
Zip	:	98074-4534
Country	:	US
Telephone Number	:	425-996-7047
Fax Number	:	425-996-7087

Provider Business Practice Location Address
First Line	:	3854 E LAKE SAMMAMISH PKWY NE
Second Line	:
City	:	SAMMAMISH
State	:	WA
Zip	:	98074-4534
Country	:	US
Telephone Number	:	425-996-7047
Fax Number	:	425-996-7087

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DONALD THOMAS STEWART
Credential	:	MO
Telephone Number	:	425-996-7047

Provider Enumeration Date	:	11/09/2007
Last Update Date	:	11/09/2007

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