Provider Demographics
NPI:1891761243
Name:EVERGREEN FAMILY MEDICAL SERVICES,P.C.
Entity Type:Organization
Organization Name:EVERGREEN FAMILY MEDICAL SERVICES,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRETOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-765-0088
Mailing Address - Street 1:743 58TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3916
Mailing Address - Country:US
Mailing Address - Phone:718-765-0088
Mailing Address - Fax:718-567-8208
Practice Address - Street 1:743 58TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3916
Practice Address - Country:US
Practice Address - Phone:718-765-0088
Practice Address - Fax:718-567-8208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-26
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02720354Medicaid
I48504Medicare UPIN
NY3334P1Medicare ID - Type Unspecified