Provider Demographics
NPI:1023006061
Name:PHD#2 OF SNOHOMISH COUNTY
Entity Type:Organization
Organization Name:PHD#2 OF SNOHOMISH COUNTY
Other - Org Name:STEVENS HOSPITAL, STEVENS MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WANGSMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-640-4113
Mailing Address - Street 1:21601 76TH AVE W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7507
Mailing Address - Country:US
Mailing Address - Phone:425-640-4000
Mailing Address - Fax:425-640-4432
Practice Address - Street 1:21601 76TH AVE W
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7507
Practice Address - Country:US
Practice Address - Phone:425-640-4000
Practice Address - Fax:425-640-4432
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHD#2 OF SNOHOMISH COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-13
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-138273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAW718582OtherCHAMPUS
WAMC150OtherPREMERA BLUE CROSS
WAST0092OtherREGENCE BLUE SHIELD
WA150OtherPREMERA BLUE CROSS
WA11031OtherWA DEPT OF L&I
WA0288OtherREGENCE BLUE SHIELD
WA3500071Medicaid
WAHP150OtherPREMERA BLUE CROSS
WA0065668OtherAETNA
WA6580520OtherAETNA
WA3500071Medicaid