Provider Demographics
NPI:1841696911
Name:EVERGREEN HOSPICE AND PALLIATIVE CARE
Entity type:Organization
Organization Name:EVERGREEN HOSPICE AND PALLIATIVE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BAUDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD ABFM/GERIATRICS
Authorized Official - Phone:602-218-0811
Mailing Address - Street 1:PO BOX 2146
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-2146
Mailing Address - Country:US
Mailing Address - Phone:602-218-0811
Mailing Address - Fax:
Practice Address - Street 1:454 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-6663
Practice Address - Country:US
Practice Address - Phone:602-549-1905
Practice Address - Fax:888-432-7480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based