Provider Demographics
NPI:1649227380
Name:PUBLIC HOSPITAL DISTRICT #1 OF KING COUNTY
Entity Type:Organization
Organization Name:PUBLIC HOSPITAL DISTRICT #1 OF KING COUNTY
Other - Org Name:VMC FAIRWOOD PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TECHNICAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:425-917-6282
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-4934
Mailing Address - Country:US
Mailing Address - Phone:425-656-5412
Mailing Address - Fax:425-656-5423
Practice Address - Street 1:14410 SE PETROVITSKY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8900
Practice Address - Country:US
Practice Address - Phone:425-656-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7095839Medicaid
WAGAB36071Medicare PIN