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General NPI Number Information
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NPI Number | 1922095694
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Entity Type | Organization
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Legal Business Name | EVERGREEN RADIA LLC
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Dates
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Enumeration Date | 09/28/2005
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Last Update Date | 09/12/2018
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Provider Practice Location Address
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Address Line | 11521 NE 128TH ST SUITE 200
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City | KIRKLAND
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State | WA
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Zip | 98034-4317
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Country | US
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Telephone | 425-952-6100
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Fax | 425-952-6150
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Provider Business Mailing Address
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Address Line | 19020 33RD AVE W STE 210
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City | LYNNWOOD
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State | WA
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Zip | 98036-4748
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Country | US
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Telephone | 425-563-1500
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Fax | 425-563-1501
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Authorized Official
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Title or Position | PRESIDENT
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Name | LLOYD STAMBAUGH
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Credential | MD
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Telephone | 425-563-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 602317167
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License Number State | WA
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