Basic Information
| Provider Information | |||||||||
| NPI: | 1780972562 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WALLA WALLA GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVENTIST HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095220100 | ||||||||
| FaxNumber: | 5095278010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095220100 | ||||||||
| FaxNumber: | 5095278010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 07/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | KNITTEL | ||||||||
| AuthorizedOfficialFirstName: | MONTY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5095250480 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 36300628 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1093362 | 05 | WA | MEDICAID |