Provider Demographics
NPI:1568527539
Name:EVERGREEN CHILDREN'S CLINIC, PLLC
Entity Type:Organization
Organization Name:EVERGREEN CHILDREN'S CLINIC, PLLC
Other - Org Name:PEDIATRICS PM
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:I
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-848-2303
Mailing Address - Street 1:1910 S MERIDIAN
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7531
Mailing Address - Country:US
Mailing Address - Phone:253-848-2303
Mailing Address - Fax:253-848-8956
Practice Address - Street 1:1910 S MERIDIAN
Practice Address - Street 2:SUITE A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7531
Practice Address - Country:US
Practice Address - Phone:253-848-2303
Practice Address - Fax:253-848-8956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7054364Medicaid