1417058694 NPI number — PUBLIC HOSPITAL DISTRICT NO 2

Table of content: (NPI 1417058694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417058694 NPI number — PUBLIC HOSPITAL DISTRICT NO 2

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUBLIC HOSPITAL DISTRICT NO 2
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVERGREEN MEDICAL GROUP SAMMAMISH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417058694
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 34036
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-1036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-899-3292
Provider Business Mailing Address Fax Number:
425-899-3269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22850 NE 8TH ST
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
SAMMAMISH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98074-7256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-898-0305
Provider Business Practice Location Address Fax Number:
425-898-8825
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALTE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
425-899-2610

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CG2833 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CG8137 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7099849 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CJ9678 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CQ2437 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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