Provider Demographics
NPI:1174710966
Name:EVERGREEN NEUROLOGY CLINIC, PLLC
Entity type:Organization
Organization Name:EVERGREEN NEUROLOGY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-822-1214
Mailing Address - Street 1:PO BOX 69737
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98168-8737
Mailing Address - Country:US
Mailing Address - Phone:206-431-0138
Mailing Address - Fax:206-246-5819
Practice Address - Street 1:12303 NE 130TH LN
Practice Address - Street 2:SUITE 325
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3099
Practice Address - Country:US
Practice Address - Phone:425-822-1214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8869704Medicare PIN