Provider Demographics
NPI:1164876322
Name:EVERGREENHEALTH
Entity Type:Organization
Organization Name:EVERGREENHEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-899-6800
Mailing Address - Street 1:11521 NE 128TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4317
Mailing Address - Country:US
Mailing Address - Phone:425-899-6797
Mailing Address - Fax:425-899-6808
Practice Address - Street 1:11521 NE 128TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4317
Practice Address - Country:US
Practice Address - Phone:425-899-6797
Practice Address - Fax:425-899-6808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60004517261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care