Basic Information
| Provider Information | |||||||||
| NPI: | 1083948582 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID-COLUMBIA FAMILY PHYSICIANS,P.S. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MID COLUMBIA FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1519 | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986721519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094932133 | ||||||||
| FaxNumber: | 5094939538 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986721519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094932133 | ||||||||
| FaxNumber: | 5094939538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2009 | ||||||||
| LastUpdateDate: | 11/16/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FITZSIMMONS | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5094932133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 600416746 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207Q00000X | 600416746 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7590037 | 05 | WA | MEDICAID |