Basic Information
| Provider Information | |||||||||
| NPI: | 1871833772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-COLUMBIA MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | COLUMBIA RIVER WOMEN'S CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1520 | ||||||||
| Address2: | 1810 E. 19TH ST. STE.209 | ||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412965657 | ||||||||
| FaxNumber: | 5412985199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1810 E 19TH ST STE 209 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412965657 | ||||||||
| FaxNumber: | 5412985199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2013 | ||||||||
| LastUpdateDate: | 04/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | SANDOVAL | ||||||||
| AuthorizedOfficialFirstName: | TASHA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF CREDENTIALING LEAD | ||||||||
| AuthorizedOfficialTelephone: | 5415065710 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | OR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QR1300X | 383895 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 2028140 | 05 | WA | MEDICAID | 500654923 | 05 | OR | MEDICAID |