Basic Information
| Provider Information | |||||||||
| NPI: | 1366809048 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-COLUMBIA MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCMC SURGICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1520 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412987971 | ||||||||
| FaxNumber: | 5412966431 | ||||||||
| Practice Location | |||||||||
| Address1: | 1810 E. 19TH ST. #225 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412966101 | ||||||||
| FaxNumber: | 5412960025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2016 | ||||||||
| LastUpdateDate: | 11/06/2017 | ||||||||
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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 | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 500704145 | 05 | OR | MEDICAID | 2057713 | 05 | WA | MEDICAID |