Provider Demographics
NPI:1497269989
Name:EVERGREEN DERMATOLOGY GROUP PLLC
Entity Type:Organization
Organization Name:EVERGREEN DERMATOLOGY GROUP PLLC
Other - Org Name:EVERGREEN DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:832-437-1763
Mailing Address - Street 1:2222 GREENHOUSE RD STE 1000
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-7342
Mailing Address - Country:US
Mailing Address - Phone:832-437-1763
Mailing Address - Fax:855-751-8050
Practice Address - Street 1:2222 GREENHOUSE RD STE 1000
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-7342
Practice Address - Country:US
Practice Address - Phone:832-437-1763
Practice Address - Fax:855-751-8050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-21
Last Update Date:2023-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4075207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP4075OtherSTATE LICENSE