Healthcare Provider Details

I. General information

NPI: 1275931982
Provider Name (Legal Business Name): RENOVO MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19930 BALLINGER WAY NE
SHORELINE WA
98155-1223
US

IV. Provider business mailing address

19930 BALLINGER WAY NE
SHORELINE WA
98155-1223
US

V. Phone/Fax

Practice location:
  • Phone: 425-778-2220
  • Fax:
Mailing address:
  • Phone: 425-778-2220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERYL HAMILL
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 425-778-2220