Provider Demographics
NPI:1699040857
Name:AMERIGROUP WASHINGTON, INC.
Entity Type:Organization
Organization Name:AMERIGROUP WASHINGTON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-674-4462
Mailing Address - Street 1:705 5TH AVENUE SOUTH
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104
Mailing Address - Country:US
Mailing Address - Phone:206-674-4462
Mailing Address - Fax:
Practice Address - Street 1:705 5TH AVENUE SOUTH
Practice Address - Street 2:SUITE 300
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104
Practice Address - Country:US
Practice Address - Phone:206-674-4462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIGROUP CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-20
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA500653302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA603047676Medicaid