Provider Demographics
NPI:1275931982
Name:RENOVO MEDICAL GROUP
Entity Type:Organization
Organization Name:RENOVO MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-778-2220
Mailing Address - Street 1:19930 BALLINGER WAY NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1223
Mailing Address - Country:US
Mailing Address - Phone:425-778-2220
Mailing Address - Fax:
Practice Address - Street 1:19930 BALLINGER WAY NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-1223
Practice Address - Country:US
Practice Address - Phone:425-778-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-11
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA=========OtherEIN