Basic Information
| Provider Information | |||||||||
| NPI: | 1629025333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUBLIC HOSPITAL DISTRICT #1 OF KING COUNTY | ||||||||
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| OtherOrganizationName: | VMC PEDS AT NEWCASTLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980554934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256565412 | ||||||||
| FaxNumber: | 4256565423 | ||||||||
| Practice Location | |||||||||
| Address1: | 6920 COAL CREEK PKWY SE | ||||||||
| Address2: | STE 12 | ||||||||
| City: | NEWCASTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980593147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256564095 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 01/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | FARLEY | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | TECHNICAL COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4259176282 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7071012 | 05 | WA | MEDICAID |