Healthcare Provider Details

I. General information

NPI: 1619209574
Provider Name (Legal Business Name): VALLEY MEDICAL GROUP-RENTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 43RD ST
RENTON WA
98055-5714
US

IV. Provider business mailing address

PO BOX 34876
SEATTLE WA
98124-1876
US

V. Phone/Fax

Practice location:
  • Phone: 425-228-3440
  • Fax: 425-656-5565
Mailing address:
  • Phone: 425-656-5412
  • Fax: 425-656-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH-155
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberH-155
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberH-155
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberH-155
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberH-155
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH-155
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberH-155
License Number StateWA
# 9
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberH-155
License Number StateWA
# 10
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberH-155
License Number StateWA
# 11
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberH-155
License Number StateWA
# 12
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberH-155
License Number StateWA
# 14
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberH-155
License Number StateWA
# 15
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberH-155
License Number StateWA

VIII. Authorized Official

Name: MICHELE FORGUES LACKIE
Title or Position: SENIOR VICE PRESIDENT FINANCE/CFO
Credential:
Phone: 425-690-6677