Basic Information
Provider Information | |||||||||
NPI: | 1841405206 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MID-COLUMBIA FAMILY PHYSICIANS,P.S. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MID COLUMBIA FAMILY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1519 | ||||||||
Address2: |   | ||||||||
City: | WHITE SALMON | ||||||||
State: | WA | ||||||||
PostalCode: | 986721519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094932133 | ||||||||
FaxNumber: | 5094959538 | ||||||||
Practice Location | |||||||||
Address1: | 875 ROCK CRK DRIVE SW | ||||||||
Address2: |   | ||||||||
City: | STEVENSON | ||||||||
State: | WA | ||||||||
PostalCode: | 986480875 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094274212 | ||||||||
FaxNumber: | 5094274955 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2007 | ||||||||
LastUpdateDate: | 11/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LABERGE | ||||||||
AuthorizedOfficialFirstName: | R | ||||||||
AuthorizedOfficialMiddleName: | ALLEN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5094932133 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 600416746 | WA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QR1300X | 600416746 | WA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 7065576 | 05 | WA |   | MEDICAID | 7033376 | 05 | WA |   | MEDICAID |