Provider Demographics
NPI:1902983109
Name:INTERNATIONAL COMMUNITY HEALTH SERVICES
Entity Type:Organization
Organization Name:INTERNATIONAL COMMUNITY HEALTH SERVICES
Other - Org Name:HOLLY PARK MEDICAL & DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:HERMES
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHBAZIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-788-3618
Mailing Address - Street 1:PO BOX 3007
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98114-3007
Mailing Address - Country:US
Mailing Address - Phone:206-788-3600
Mailing Address - Fax:206-652-5216
Practice Address - Street 1:3815 S OTHELLO ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-3510
Practice Address - Country:US
Practice Address - Phone:206-788-3500
Practice Address - Fax:206-788-3521
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERNATIONAL COMMUNITY HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600436519207Q00000X
251B00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7125289Medicaid
WAG000151700Medicare PIN
WA501874Medicare ID - Type UnspecifiedMEDICARE