Basic Information
| Provider Information | |||||||||
| NPI: | 1154869659 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID-COLUMBIA MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MCMC PODIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1520 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970588003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412967504 | ||||||||
| FaxNumber: | 5412966431 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 NICHOLS PKWY | ||||||||
| Address2: | |||||||||
| City: | HOOD RIVER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970313121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415066440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/14/2017 | ||||||||
| NPIReactivationDate: | 07/07/2017 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TREHARNE | ||||||||
| AuthorizedOfficialFirstName: | CHELSEA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5415067620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 14-0500 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 218105 | 05 | OR | MEDICAID |