Provider Demographics
NPI:1013004803
Name:EVERGREEN UROLOGY CONSULTANTS LLC
Entity Type:Organization
Organization Name:EVERGREEN UROLOGY CONSULTANTS LLC
Other - Org Name:ATHENA UROLGOY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORA
Authorized Official - Middle Name:
Authorized Official - Last Name:PLASKON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-392-8611
Mailing Address - Street 1:6520 226TH PL SE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8969
Mailing Address - Country:US
Mailing Address - Phone:425-392-8611
Mailing Address - Fax:425-392-9012
Practice Address - Street 1:6520 226TH PL SE
Practice Address - Street 2:SUITE 205
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8969
Practice Address - Country:US
Practice Address - Phone:425-392-8611
Practice Address - Fax:425-392-9012
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN UROLOGY CONSULTANTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-05
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADG3321OtherRAILROAD MEDICARE
WADG3321OtherRAILROAD MEDICARE