NPIMap

Organization Active NPI

Evergreen Pediatric Clinic PS

  • Pediatric Adolescent Medicine Physician
  • Vancouver, WA
National Provider Identifier
1144343773
Registry record updated Feb 21, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Adolescent Medicine PhysicianTaxonomy code 2080A0000X
License
601 115 723 Issued in WA
Legal business name
EVERGREEN PEDIATRIC CLINIC PS
Practice address
505 NE 87TH Ave
Ste 120
Vancouver, WA 98664-1989
Phone
(360) 892-1635
Fax
(360) 892-3146
NPI assigned
Apr 9, 2007
Last updated
Feb 21, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 21, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Teri Bryant
Title
Office Manager
Phone
(360) 892-1635

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Adolescent Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2080A0000X 601 115 723 WA Primary

Addresses

Primary practice location

505 NE 87TH Ave
Ste 120
Vancouver, WA 98664-1989

Mailing address

505 NE 87TH Ave
Ste 120
Vancouver, WA 98664-1989
Phone (360) 892-1635

Other identifiers 1

IdentifierTypeStateIssuer
7033186MedicaidWA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
50D0637777Evergreen Pediatric Clinic505 NE 87TH Ave Ste 120, Vancouver, WA 98664Provider-performed microscopyApr 4, 2028

National Provider Directory

National Provider Directory

Locations

2101 NE 139th St
Ste 370
Vancouver, WA 98686
Phone (360) 892-1635

505 NE 87th Ave
Ste 120
Vancouver, WA 98664
Phone (360) 892-1635

Practitioners & affiliated clinicians

Practitioners 20

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 20

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176076800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1582243200000",
    "number": "1144343773",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "505 NE 87TH AVE",
            "address_2": "STE 120",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986641989",
            "telephone_number": "360-892-1635",
            "fax_number": "360-892-3146"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "505 NE 87TH AVE",
            "address_2": "STE 120",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986641989",
            "telephone_number": "360-892-1635",
            "fax_number": "360-892-3146"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN PEDIATRIC CLINIC PS",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-09",
        "last_updated": "2020-02-21",
        "certification_date": "2020-02-21",
        "status": "A",
        "authorized_official_last_name": "BRYANT",
        "authorized_official_first_name": "TERI",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "360-892-1635"
    },
    "taxonomies": [
        {
            "code": "2080A0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": "WA",
            "license": "601 115 723",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7033186",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Vancouver, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.