Basic Information
| Provider Information | |||||||||
| NPI: | 1881763852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID COLUMBIA HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4800 | ||||||||
| Address2: | UNIT 17 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886330087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 E 19TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412961111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 08/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | ARBON | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5412961111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8922672 | 01 | WA CRIME VICTIMS | OTHER | 7058977 | 05 | WA | MEDICAID | 35236 | 01 | WORKERS COMP | OTHER | 0235001 | 01 | PREFERRED ONE | OTHER | 168114 | 05 | OR | MEDICAID |