Basic Information
| Provider Information | |||||||||
| NPI: | 1043428352 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SWEDISH EDMONDS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SWEDISH EDMONDS PSYCHIATRIC SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91000 | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980262100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256733374 | ||||||||
| FaxNumber: | 4256404455 | ||||||||
| Practice Location | |||||||||
| Address1: | 21601 76TH AVE W | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256404000 | ||||||||
| FaxNumber: | 4256404455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | FARRETTA | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4256733374 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SWEDISH EDMONDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 7060486 | 05 | WA | MEDICAID |