1255371035 NPI number — MID-COLUMBIA HEALTH SERVICES INC

Table of content: (NPI 1255371035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255371035 NPI number — MID-COLUMBIA HEALTH SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-COLUMBIA HEALTH SERVICES INC
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:
Provider Other Organization Name Type Code:
6
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:
1255371035
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 922
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THE DALLES
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97058-0922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-296-6131
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 UNION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THE DALLES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97058-1719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-6131
Provider Business Practice Location Address Fax Number:
541-296-2755
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ARBON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
O
Authorized Official Title or Position:
CFO VICE PRESIDENT
Authorized Official Telephone Number:
541-296-6131

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 074534 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 048196000 . This is a "BCBS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 0039016 . This is a "DLI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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