Provider Demographics
NPI:1710238449
Name:LLEWELLYN PHILLIPS II M.D., INC., P.S.
Entity Type:Organization
Organization Name:LLEWELLYN PHILLIPS II M.D., INC., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LLEWELLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:425-228-4900
Mailing Address - Street 1:4509 TALBOT RD S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6294
Mailing Address - Country:US
Mailing Address - Phone:425-228-4520
Mailing Address - Fax:425-226-0283
Practice Address - Street 1:4509 TALBOT RD S
Practice Address - Street 2:SUITE 200
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6294
Practice Address - Country:US
Practice Address - Phone:425-228-4520
Practice Address - Fax:425-226-0283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013579207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP618OtherREGENCE BCBS
WA071661015OtherRAILROAD MEDICARE
WA120734144076OtherPREMERA BLUE CROSS
WA1681105Medicaid
WA120734144076OtherPREMERA BLUE CROSS
WAG000104173Medicare PIN