Basic Information
| Provider Information | |||||||||
| NPI: | 1760455687 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIC HOSPITAL DISTRICT NO. 2, KLICKITAT COUNTY, WASHINGTON | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SKYLINE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99 | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986720099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094931101 | ||||||||
| FaxNumber: | 5094932838 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 SKYLINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986720099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094931101 | ||||||||
| FaxNumber: | 5094932838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIMMES | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5096372919 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | H-096 | WA | N | Hospitals | General Acute Care Hospital | Critical Access | 341600000X | WA | N | Transportation Services | Ambulance | 282NC0060X | WA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 8117327 | 05 | WA | MEDICAID | SK6515 | 01 | WA | REGENCE OP # | OTHER | 9162306 | 05 | WA | MEDICAID | SK0315 | 01 | WA | REGENCE IP # | OTHER | 184713 | 05 | OR | MEDICAID | 9060SK | 01 | WA | REGENCE AMB # | OTHER | 3300209 | 05 | WA | MEDICAID | 3620705 | 05 | WA | MEDICAID |