1023006061 NPI number — PHD#2 OF SNOHOMISH COUNTY

Table of content: (NPI 1023006061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023006061 NPI number — PHD#2 OF SNOHOMISH COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHD#2 OF SNOHOMISH COUNTY
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:
STEVENS HOSPITAL, STEVENS MEMORIAL HOSPITAL
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:
1023006061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21601 76TH AVE W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMONDS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98026-7507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-640-4000
Provider Business Mailing Address Fax Number:
425-640-4432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21601 76TH AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98026-7507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-640-4000
Provider Business Practice Location Address Fax Number:
425-640-4432
Provider Enumeration Date:
10/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WANGSMO
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
425-640-4113

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X , with the licence number:  H-138 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: W718582 . This is a "CHAMPUS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: MC150 . This is a "PREMERA BLUE CROSS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: ST0092 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 150 . This is a "PREMERA BLUE CROSS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 11031 . This is a "WA DEPT OF L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0288 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3500071 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP150 . This is a "PREMERA BLUE CROSS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0065668 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 6580520 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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