Basic Information
| Provider Information | |||||||||
| NPI: | 1023006061 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHD#2 OF SNOHOMISH COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | STEVENS HOSPITAL, STEVENS MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 21601 76TH AVE W | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256404000 | ||||||||
| FaxNumber: | 4256404432 | ||||||||
| Practice Location | |||||||||
| Address1: | 21601 76TH AVE W | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256404000 | ||||||||
| FaxNumber: | 4256404432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 08/28/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WANGSMO | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4256404113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHD#2 OF SNOHOMISH COUNTY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | H-138 | WA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | W718582 | 01 | WA | CHAMPUS | OTHER | MC150 | 01 | WA | PREMERA BLUE CROSS | OTHER | ST0092 | 01 | WA | REGENCE BLUE SHIELD | OTHER | 150 | 01 | WA | PREMERA BLUE CROSS | OTHER | 11031 | 01 | WA | WA DEPT OF L&I | OTHER | 0288 | 01 | WA | REGENCE BLUE SHIELD | OTHER | 3500071 | 05 | WA | MEDICAID | HP150 | 01 | WA | PREMERA BLUE CROSS | OTHER | 0065668 | 01 | WA | AETNA | OTHER | 6580520 | 01 | WA | AETNA | OTHER |