Basic Information
Provider Information | |||||||||
NPI: | 1912947565 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PUBLIC HOSPITAL DISTRICT #1 OF KING COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VMC VALLEY VASCULAR SURGERY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 4033 TALBOT RD S | ||||||||
Address2: | SUITE 530 | ||||||||
City: | RENTON | ||||||||
State: | WA | ||||||||
PostalCode: | 980555772 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4256565568 | ||||||||
FaxNumber: | 4256565578 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 01/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FARLEY | ||||||||
AuthorizedOfficialFirstName: | MELISSA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | TECHNICAL COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 4259176282 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0129X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 7060353 | 05 | WA |   | MEDICAID |