Provider Demographics
NPI:1275675530
Name:OPTUM CARE WASHINGTON PLLC
Entity Type:Organization
Organization Name:OPTUM CARE WASHINGTON PLLC
Other - Org Name:OPTUM - PAVILION FOR WOMEN AND CHILDREN
Other - Org Type:Other Name
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-259-0966
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4168
Practice Address - Country:US
Practice Address - Phone:425-339-5430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERETT PHYSICIANS, INC. P.S.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-13
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X, 332B00000X
WA50D0998446291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA33000OtherL&I
WA7776503Medicaid
WA33000OtherL&I
=========OtherTAX ID