Provider Demographics
NPI:1013979624
Name:PHD2 OF SNOHOMISH COUNTY
Entity Type:Organization
Organization Name:PHD2 OF SNOHOMISH COUNTY
Other - Org Name:STEVENS CENTER FOR INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WANGSMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-640-4113
Mailing Address - Street 1:7320 216TH ST SW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8006
Mailing Address - Country:US
Mailing Address - Phone:425-640-4901
Mailing Address - Fax:425-640-4919
Practice Address - Street 1:7320 216TH ST SW
Practice Address - Street 2:SUITE 200
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8006
Practice Address - Country:US
Practice Address - Phone:425-640-4901
Practice Address - Fax:425-640-4919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG1766OtherMEDICARE RAILROAD GROUP
WADE0413OtherMEDICARE RAILROAD GROUP
WA35870OtherLABOR AND INDUSTRIES
WADB5880OtherMEDICARE RAILROAD GROUP
WA7059371Medicaid
WACJ4104OtherMEDICARE RAILROAD GROUP