MEDICARE: EASTSIDE DERMATOLOGY INC PS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207N00000X	Dermatology Physician
2	207NS0135X	Procedural Dermatology Physician
3	207NP0225X	Pediatric Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	CN9262	OTHER	WA	RAILROAD MEDIACRE

General Provider Information

NPI Number	:	1649379231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTSIDE DERMATOLOGY INC PS

Provider Business Mailing Address
First Line	:	14030 NE 24TH ST
Second Line	:	SUITE 202
City	:	BELLEVUE
State	:	WA
Zip	:	98007-3724
Country	:	US
Telephone Number	:	425-454-1104
Fax Number	:	425-454-1290

Provider Business Practice Location Address
First Line	:	14030 NE 24TH ST
Second Line	:	SUITE 202
City	:	BELLEVUE
State	:	WA
Zip	:	98007-3724
Country	:	US
Telephone Number	:	425-454-1104
Fax Number	:	425-454-1290

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. MELANIE A JENNINGS
Credential	:
Telephone Number	:	425-454-1104

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	09/11/2025

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