Provider Demographics
NPI:1922095694
Name:EVERGREEN RADIA LLC
Entity Type:Organization
Organization Name:EVERGREEN RADIA LLC
Other - Org Name:EVERGREEN RADIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:STAMBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-563-1500
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1501
Practice Address - Street 1:11521 NE 128TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4317
Practice Address - Country:US
Practice Address - Phone:425-952-6100
Practice Address - Fax:425-952-6150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-28
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6023171672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7118227Medicaid
WA175238OtherGROUP LABOR & INDUSTRIES
WA8933574OtherGROUP CRIME VICTIMS
WAAB39931Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER