Provider Demographics
NPI:1497766190
Name:EVERGREEN DIABETES & ENDOCRINOLOGY MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:EVERGREEN DIABETES & ENDOCRINOLOGY MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:COURTRIGHT
Authorized Official - Last Name:LA CAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-899-6414
Mailing Address - Street 1:13118 121 WAY NE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3004
Mailing Address - Country:US
Mailing Address - Phone:425-899-6414
Mailing Address - Fax:425-899-4066
Practice Address - Street 1:13118 121ST WAY NE
Practice Address - Street 2:SUITE 103
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3004
Practice Address - Country:US
Practice Address - Phone:425-899-6414
Practice Address - Fax:425-899-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602612648207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8868331Medicare PIN