Basic Information
| Provider Information | |||||||||
| NPI: | 1851748578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE EVERETT CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5127 | ||||||||
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| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982065127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252583900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 N 175TH ST | ||||||||
| Address2: | |||||||||
| City: | SHORELINE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981335064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252590966 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2016 | ||||||||
| LastUpdateDate: | 02/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | RODEWALD | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4253395460 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAVITA EVERETT PHYSICIANS, INC. P.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 291U00000X | 50D2116268 | WA | N | Laboratories | Clinical Medical Laboratory | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.