Provider Demographics
NPI:1700074275
Name:EVERGREEN MEDICAL PANEL
Entity Type:Organization
Organization Name:EVERGREEN MEDICAL PANEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATIES
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSY
Authorized Official - Middle Name:E
Authorized Official - Last Name:ANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-576-4171
Mailing Address - Street 1:2411 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2954
Mailing Address - Country:US
Mailing Address - Phone:253-572-4171
Mailing Address - Fax:253-572-4291
Practice Address - Street 1:2411 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2954
Practice Address - Country:US
Practice Address - Phone:253-572-4171
Practice Address - Fax:253-572-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0700013011302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization