Provider Demographics
NPI:1922540004
Name:KING COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Entity Type:Organization
Organization Name:KING COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Other - Org Name:EVERGREENHEALTH LAKESHORE TOTEM LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MALTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-899-2610
Mailing Address - Street 1:10131 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3425
Mailing Address - Country:US
Mailing Address - Phone:425-485-3955
Mailing Address - Fax:425-485-1476
Practice Address - Street 1:12710 TOTEM LAKE BLVD NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2907
Practice Address - Country:US
Practice Address - Phone:425-821-4040
Practice Address - Fax:425-820-5060
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KING COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-07
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207Q00000X, 207R00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty