MEDICARE: DR. EVELYN EBARLE EBALO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	MD00028453	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	EB5698	OTHER	WA	REGENCE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881671618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVELYN EBARLE EBALO M.D.

Provider Business Mailing Address
First Line	:	1920 BLACK LAKE BLVD SW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98512-5651
Country	:	US
Telephone Number	:	360-534-9222
Fax Number	:	360-534-9223

Provider Business Practice Location Address
First Line	:	1920 BLACK LAKE BLVD SW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98512-5651
Country	:	US
Telephone Number	:	360-534-9222
Fax Number	:	360-534-9223

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	07/08/2007

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