Organization
SOUTHLAKE CLINIC INC., P.S.
Active
Other names
Valley Internal Medicine Inc PS
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JAMES DWIGHT HUDSON MHA (COO)
(425) 793-4725
Entity
Organization
Contact information
Practice address
4011 TALBOT RD S, SUITE 500, RENTON, WA 98055-5773
(425) 251-5110
(425) 793-4707
Mailing address
PO BOX 59028, RENTON, WA 98058-2028
(425) 251-5110
(425) 277-1301
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
—
—
207R00000X
Internal Medicine Physician
Primary
—
—
207RC0000X
Cardiovascular Disease Physician
—
—
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
—
—
207RE0101X
Endocrinology, Diabetes & Metabolism Physician
—
—
207RG0100X
Gastroenterology Physician
—
—
207RH0003X
Hematology & Oncology Physician
—
—
207RI0011X
Interventional Cardiology Physician
—
—
207RI0200X
Infectious Disease Physician
—
—
207RP1001X
Pulmonary Disease Physician
—
—
207RS0012X
Sleep Medicine (Internal Medicine) Physician
—
—
207UN0901X
Nuclear Cardiology Physician
—
—
208M00000X
Hospitalist Physician
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0057600
L&I
WA
05
—
7072440
—
WA
01
—
CS3809
RR MEDICARE
WA
Enumeration date
01/29/2007
Last updated
07/13/2017
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