Provider Demographics
NPI:1033164470
Name:PUBLIC HOSPITAL DIST NO 1 SKAGIT
Entity Type:Organization
Organization Name:PUBLIC HOSPITAL DIST NO 1 SKAGIT
Other - Org Name:SKAGIT REGIONAL HEALTH - GRANITE FALLS FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ISHIZUKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-814-5838
Mailing Address - Street 1:1400 E. KINCAID STREET
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:405 W. STANLEY STREET
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:WA
Practice Address - Zip Code:98252-8631
Practice Address - Country:US
Practice Address - Phone:360-619-2419
Practice Address - Fax:360-691-0489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
WAHAC.FS.00000106207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2058859Medicaid
WA2058859Medicaid
WA1000814Medicaid