Provider Demographics
NPI:1023165594
Name:EASTSIDE INTERNAL MEDICINE PLLC
Entity type:Organization
Organization Name:EASTSIDE INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:PORTELANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-899-6700
Mailing Address - Street 1:12333 NE 120TH LN. STE 310
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12333 NE 120TH LN. STE 310
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034
Practice Address - Country:US
Practice Address - Phone:425-899-6700
Practice Address - Fax:425-899-6701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA145684OtherLABOR & INDUSTRIES
WA145684OtherLABOR & INDUSTRIES