Basic Information
| Provider Information | |||||||||
| NPI: | 1922095694 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVERGREEN RADIA LLC | ||||||||
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| OtherOrganizationName: | EVERGREEN RADIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631501 | ||||||||
| Practice Location | |||||||||
| Address1: | 11521 NE 128TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980344317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259526100 | ||||||||
| FaxNumber: | 4259526150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2005 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | STAMBAUGH | ||||||||
| AuthorizedOfficialFirstName: | LLOYD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4255631500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 602317167 | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7118227 | 05 | WA | MEDICAID | 175238 | 01 | WA | GROUP LABOR & INDUSTRIES | OTHER | 8933574 | 01 | WA | GROUP CRIME VICTIMS | OTHER |