Basic Information
| Provider Information | |||||||||
| NPI: | 1992094817 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID-COLUMBIA MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCMC OCCUPATIONAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1520 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970588003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415066920 | ||||||||
| FaxNumber: | 5412965451 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 E 19TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415066920 | ||||||||
| FaxNumber: | 5412965451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2011 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SANDOVAL | ||||||||
| AuthorizedOfficialFirstName: | TASHA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF CREDENTIALING LEAD | ||||||||
| AuthorizedOfficialTelephone: | 5415065710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2013509 | 05 | WA | MEDICAID | 500636659 | 05 | OR | MEDICAID |