Provider Demographics
NPI:1578653747
Name:PUBLIC HOSPITAL DISTRICT NO 2
Entity Type:Organization
Organization Name:PUBLIC HOSPITAL DISTRICT NO 2
Other - Org Name:EVERGREEN MEDICAL GROUP REDMOND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MALTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-899-2610
Mailing Address - Street 1:PO BOX 34036
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1036
Mailing Address - Country:US
Mailing Address - Phone:425-899-3292
Mailing Address - Fax:425-899-3269
Practice Address - Street 1:8301 161ST AVE NE
Practice Address - Street 2:STE 308
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3858
Practice Address - Country:US
Practice Address - Phone:425-882-5020
Practice Address - Fax:425-882-5021
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUBLIC HOSPITAL DISTRICT NO 2
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-16
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG8137OtherMEDICARE RAILROAD
WACJ9678OtherMEDICARE RAILROAD
WACQ2437OtherMEDICARE RAILROAD
WA7072333Medicaid
WACG2833OtherMEDICARE RAILROAD
WA7072333Medicaid