Basic Information
Provider Information | |||||||||
NPI: | 1407887052 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MID-COLUMBIA MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WATER'S EDGE MEDICAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 551 LONE PINE BLVD | ||||||||
Address2: | PO BOX 1520 | ||||||||
City: | THE DALLES | ||||||||
State: | OR | ||||||||
PostalCode: | 97058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415066920 | ||||||||
FaxNumber: | 5412965451 | ||||||||
Practice Location | |||||||||
Address1: | 551 LONE PINE BLVD | ||||||||
Address2: |   | ||||||||
City: | THE DALLES | ||||||||
State: | OR | ||||||||
PostalCode: | 97058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415066920 | ||||||||
FaxNumber: | 5412965451 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 08/29/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SANDOVAL | ||||||||
AuthorizedOfficialFirstName: | TASHA | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL STAFF CREDENTIALING LEAD | ||||||||
AuthorizedOfficialTelephone: | 5415065710 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 261QU0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 363LF0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 218103 | 05 | OR |   | MEDICAID | 276258 | 05 | OR |   | MEDICAID | 1009681 | 05 | WA |   | MEDICAID |