1992094817 NPI number — MID-COLUMBIA MEDICAL CENTER

Table of content: (NPI 1992094817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992094817 NPI number — MID-COLUMBIA MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-COLUMBIA MEDICAL CENTER
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:
1992094817
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1520
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:
97058-8003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-506-6920
Provider Business Mailing Address Fax Number:
541-296-5451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1825 E 19TH 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:
97058-3365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-506-6920
Provider Business Practice Location Address Fax Number:
541-296-5451
Provider Enumeration Date:
03/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KNOX
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CORPORATE OFFICER CEO
Authorized Official Telephone Number:
541-296-7273

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2013509 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500636659 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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