Southlake Clinic Inc., P.S.

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

Legal business name

SOUTHLAKE CLINIC INC., P.S.

Practice address

4011 Talbot Rd S
Suite 500
Renton, WA 98055-5773

Phone

(425) 251-5110

Fax

(425) 793-4707

NPI assigned

Jan 29, 2007

Last updated

Jul 13, 2017By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. James Dwight Hudson, MHA

Title

Coo

Phone

(425) 793-4725

Specialties & licenses 15

Addresses

Other identifiers 3

Other names 1

• Valley Internal Medicine Inc PS Former legal business name

Locations

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

• Southlake Clinic DME

  • Durable Medical Equipment & Medical Supplies
  • Renton, WA
  • NPI 1821237488
  NPPES parent name

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Ronald L Brazg, MD

  • Endocrinology, Diabetes & Metabolism Physician
  • Renton, WA
  • NPI 1194746131
  NPD (past)
• Allen M Sussman, MD

  • Endocrinology, Diabetes & Metabolism Physician
  • Renton, WA
  • NPI 1710991237
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170028800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1499904000000",
    "number": "1104962331",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 59028",
            "city": "RENTON",
            "state": "WA",
            "postal_code": "980582028",
            "telephone_number": "425-251-5110",
            "fax_number": "425-277-1301"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4011 TALBOT RD S",
            "address_2": "SUITE 500",
            "city": "RENTON",
            "state": "WA",
            "postal_code": "980555773",
            "telephone_number": "425-251-5110",
            "fax_number": "425-793-4707"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHLAKE CLINIC INC., P.S.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-29",
        "last_updated": "2017-07-13",
        "status": "A",
        "authorized_official_last_name": "HUDSON",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "DWIGHT",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "425-793-4725",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MHA"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RC0200X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Critical Care Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RE0101X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Endocrinology, Diabetes & Metabolism",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RG0100X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Gastroenterology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RH0003X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Hematology & Oncology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RI0011X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RI0200X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Infectious Disease",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207UN0901X",
            "taxonomy_group": "",
            "desc": "Nuclear Medicine, Nuclear Cardiology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208M00000X",
            "taxonomy_group": "",
            "desc": "Hospitalist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RS0012X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Sleep Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "CS3809",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "L&I",
            "identifier": "0057600",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7072440",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Valley Internal Medicine Inc PS",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• Southlake Clinic DME
• Southlake Clinic Inc PS
• Southlake Clinic Inc PS (Southlake Clinic)
• Southlake Clinic Inc PS (Southlake Clinic Pathology)
• Southlake Clinic Inc PS
• Southlake Psychiatric Center
• Southlake Select, PC
• Southwest 2ND Street Healthcare LLC (Renton Health & Rehabilitation)
• Marieme Sow
• Space for Grief

• Internal Medicine Physician in Renton, WA
• Providers in Renton, WA by specialty
• Internal Medicine Physician in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.