Basic Information
| Provider Information | |||||||||
| NPI: | 1750612883 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KING COUNTY PUBLIC HOSPITAL DISTRICT NO. 2 | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EVERGREENHEALTH MEDICAL GROUP KING COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34036 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258993292 | ||||||||
| FaxNumber: | 4258993269 | ||||||||
| Practice Location | |||||||||
| Address1: | 8980 161ST AVE NE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980527554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258992273 | ||||||||
| FaxNumber: | 4258992272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2010 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MYCROFT | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTINE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4258992606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KING COUNTY PUBLIC HOSPITAL DISTRICT NO 2 | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | CQ2437 | 01 | WA | MEDICARE RAILROAD | OTHER |