1710238449 NPI number — LLEWELLYN PHILLIPS II M.D., INC., P.S.

Table of content: (NPI 1710238449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710238449 NPI number — LLEWELLYN PHILLIPS II M.D., INC., P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LLEWELLYN PHILLIPS II M.D., INC., P.S.
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:
Provider Other Organization Name Type Code:
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:
1710238449
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4509 TALBOT RD S
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98055-6294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-228-4520
Provider Business Mailing Address Fax Number:
425-226-0283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4509 TALBOT RD S
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98055-6294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-228-4520
Provider Business Practice Location Address Fax Number:
425-226-0283
Provider Enumeration Date:
09/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
LLEWELLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
425-228-4900

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  MD00013579 , 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: P618 . This is a "REGENCE BCBS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 071661015 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 120734144076 . This is a "PREMERA BLUE CROSS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1681105 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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