Basic Information
| Provider Information | |||||||||
| NPI: | 1053551697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-COLUMBIA MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | ORTHOPAEDIC SERVICES AT MCMC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 551 LONE PINE BLVD | ||||||||
| Address2: | PO BOX 1520 | ||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415066500 | ||||||||
| FaxNumber: | 5415066501 | ||||||||
| Practice Location | |||||||||
| Address1: | 551 LONE PINE BLVD | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415066500 | ||||||||
| FaxNumber: | 5415066501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | KNOX | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 5412967273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MID-COLUMBIA MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0117X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XX0004X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0005X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0801X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 282NR1301X | N | Hospitals | General Acute Care Hospital | Rural | 207X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 197434 | 05 | OR | MEDICAID | 000070 | 05 | OR | MEDICAID |