Provider Demographics
| NPI: | 1619209574 |
|---|---|
| Name: | VALLEY MEDICAL GROUP-RENTON |
| Entity Type: | Organization |
| Organization Name: | VALLEY MEDICAL GROUP-RENTON |
| Other - Org Name: | PUBLIC HOSPITAL DISTRICT #1 OF KING COUNTY |
| Other - Org Type: | Other Name |
| Authorized Official - Title/Position: | SENIOR VICE PRESIDENT FINANCE/CFO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | MICHELE |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | FORGUES LACKIE |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 425-690-6677 |
| Mailing Address - Street 1: | PO BOX 34876 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | SEATTLE |
| Mailing Address - State: | WA |
| Mailing Address - Zip Code: | 98124-1876 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 425-656-5412 |
| Mailing Address - Fax: | 425-656-4096 |
| Practice Address - Street 1: | 400 S 43RD ST |
| Practice Address - Street 2: | |
| Practice Address - City: | RENTON |
| Practice Address - State: | WA |
| Practice Address - Zip Code: | 98055-5714 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 425-228-3440 |
| Practice Address - Fax: | 425-656-5565 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | PUBLIC HOSPITAL DISTRICT #1 OF KING COUNTY |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2010-02-03 |
| Last Update Date: | 2023-03-22 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| WA | H-155 | 207Q00000X, 207R00000X, 207T00000X, 207VG0400X, 207W00000X, 208000000X, 2084N0400X, 208600000X, 2086S0129X, 208M00000X, 282N00000X, 363L00000X, 367A00000X |
| 208100000X, 251S00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 282N00000X | Hospitals | General Acute Care Hospital | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
| No | 207VG0400X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | Group - Multi-Specialty |
| No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 251S00000X | Agencies | Community/Behavioral Health | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| WA | 1008494 | Medicaid | |
| WA | 1008494 | Medicaid | |
| WA | 500088 | Medicare Oscar/Certification |
