1699720797 NPI number — GRANT COUNTY PUBLIC HOSPITAL DISTRICT 5

Table of content: (NPI 1699720797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699720797 NPI number — GRANT COUNTY PUBLIC HOSPITAL DISTRICT 5

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANT COUNTY PUBLIC HOSPITAL DISTRICT 5
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MATTAWA COMMUNITY MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699720797
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1581
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTAWA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99349-0960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-932-4499
Provider Business Mailing Address Fax Number:
509-932-5363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 GOVERNMENT ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTAWA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99349-0960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-932-4499
Provider Business Practice Location Address Fax Number:
509-932-5363
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
DANA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CEO/EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
509-932-4499

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7900657 . This is a "DSHS TAKE CHARGE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 501944 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 67850 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7035611 . This is a "DSHS FEE FOR SERVICE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7406572 . This is a "DSHS MSS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7044167 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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