Basic Information
| Provider Information | |||||||||
| NPI: | 1053409599 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-COLUMBIA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 E 19TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412967668 | ||||||||
| FaxNumber: | 5412967619 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 E 19TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412961111 | ||||||||
| FaxNumber: | 5412967619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANDOVAL | ||||||||
| AuthorizedOfficialFirstName: | TASHA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF CREDENTIALING LEAD | ||||||||
| AuthorizedOfficialTelephone: | 5415065710 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 2008493 | 05 | WA | MEDICAID | 070115 | 05 | OR | MEDICAID |