Basic Information
| Provider Information | |||||||||
| NPI: | 1912026360 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEND OREILLE COUNTY PUBLIC HOSPITAL DISTRICT NO 1 | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEWPORT HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 714 W PINE ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991569046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094474885 | ||||||||
| FaxNumber: | 5094470456 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 W PINE ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991569046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094474885 | ||||||||
| FaxNumber: | 5094470456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | WILBUR | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5094472441 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | 264000780 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 7098395 | 05 | WA | MEDICAID | 7105455 | 05 | WA | MEDICAID | 805262500 | 05 | ID | MEDICAID |