Provider Demographics
NPI:1689655334
Name:EVERGREEN SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:EVERGREEN SURGERY CENTER, LLC
Other - Org Name:EVERGREEN SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-899-5656
Mailing Address - Street 1:12333 NE 130TH LN
Mailing Address - Street 2:SUITE 500
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-7467
Mailing Address - Country:US
Mailing Address - Phone:425-899-5656
Mailing Address - Fax:425-899-5638
Practice Address - Street 1:12333 NE 130TH LN
Practice Address - Street 2:SUITE 500
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7467
Practice Address - Country:US
Practice Address - Phone:425-899-5656
Practice Address - Fax:425-899-5638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7123631Medicaid
WA7123631Medicaid