Basic Information
| Provider Information | |||||||||
| NPI: | 1154351336 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-COLUMBIA MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | MCMC FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1620 E 12TH ST | ||||||||
| Address2: | PO BOX 1520 | ||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412969151 | ||||||||
| FaxNumber: | 5412969156 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 E 12TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412969151 | ||||||||
| FaxNumber: | 5412969156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 09/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | TREHARNE | ||||||||
| AuthorizedOfficialFirstName: | CHELSEA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5415067620 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QR1300X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1003624 | 05 | WA | MEDICAID | 218112 | 05 | OR | MEDICAID |