NPIMap

Organization Active NPI

Public Hospital District No 2

Doing business as Evergreen Medical Group Kenmore

  • Family Medicine Physician
  • Kenmore, WA
National Provider Identifier
1629179890
Registry record updated Jan 4, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
PUBLIC HOSPITAL DISTRICT NO 2
Doing business as
Evergreen Medical Group Kenmore
Practice address
18208 66TH Ave NE
Ste 200
Kenmore, WA 98028-7949
Phone
(425) 485-6561
Fax
(425) 488-4939
NPI assigned
Sep 26, 2006
Last updated
Jan 4, 2011By the provider in NPPES
Organization subpart
Yes
Parent organization
PUBLIC HOSPITAL DISTRICT NO 2As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 4, 2011

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

Authorized official

Name
Robert Malte
Title
Ceo
Phone
(425) 899-2610

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

18208 66TH Ave NE
Ste 200
Kenmore, WA 98028-7949

Mailing address

PO Box 34036
Seattle, WA 98124-1036
Phone (425) 899-3292

Other identifiers 5

IdentifierTypeStateIssuer
CQ2437OtherWAMEDICARE RAILROAD
7073323MedicaidWA
CG8137OtherWAMEDICARE RAILROAD
CG2833OtherWAMEDICARE RAILROAD
CJ9678OtherWAMEDICARE RAILROAD

Other names 1

  • Evergreen Medical Group Kenmore Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031111000557 WA Part B Supplier - Clinic/Group Practice 7618880097 Receives reassigned benefits from 1,160 practitioners
27 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Kirkland, WA; Mill Creek, WA; Monroe, WA; Redmond, WA; Sammamish, WA; Sultan, WA; Woodinville, WA; Bothell, WA…

Other NPIs on the same Medicare enrollment 27

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 27

National Provider Directory

National Provider Directory
Part of
Public Hosp District No 2

Locations

18208 66th Ave NE
Ste 200
Kenmore, WA 98028
Phone (425) 286-0466

Practitioners & affiliated clinicians

Practitioners 8

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.

NPI Registry JSON

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

{
    "created_epoch": "1159228800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1294099200000",
    "number": "1629179890",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 34036",
            "city": "SEATTLE",
            "state": "WA",
            "postal_code": "981241036",
            "telephone_number": "425-899-3292",
            "fax_number": "425-899-3269"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18208 66TH AVE NE",
            "address_2": "STE 200",
            "city": "KENMORE",
            "state": "WA",
            "postal_code": "980287949",
            "telephone_number": "425-485-6561",
            "fax_number": "425-488-4939"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PUBLIC HOSPITAL DISTRICT NO 2",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PUBLIC HOSPITAL DISTRICT NO 2",
        "enumeration_date": "2006-09-26",
        "last_updated": "2011-01-04",
        "status": "A",
        "authorized_official_last_name": "MALTE",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "425-899-2610"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "CQ2437",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7073323",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "CG8137",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "CG2833",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "CJ9678",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Medical Group Kenmore",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kenmore, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 4, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.