Provider Demographics
NPI:1619912524
Name:EVERGREEN EMERGENCY SERVICES, PS
Entity Type:Organization
Organization Name:EVERGREEN EMERGENCY SERVICES, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CRYSTAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-899-1751
Mailing Address - Street 1:FILE 50421
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:855-691-9890
Mailing Address - Fax:
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:206-550-5253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
184567OtherWASHINGTON CRIME VICTIMS
WA7122864Medicaid
8938298OtherWASHINGTON CRIME VICTIMS
604658700OtherUS DEPTARMENT OF LABOR
WA7122864Medicaid
WA8802602Medicare PIN
WA7122864Medicaid