Provider Demographics
NPI:1063646107
Name:PULLMAN REGIONAL HOSPITAL CLINIC NETWORK LLC
Entity Type:Organization
Organization Name:PULLMAN REGIONAL HOSPITAL CLINIC NETWORK LLC
Other - Org Name:PALOUSE PEDIATRICS - PULLMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FEBUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-332-6139
Mailing Address - Street 1:840 SE BISHOP BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5502
Mailing Address - Country:US
Mailing Address - Phone:509-332-6139
Mailing Address - Fax:509-332-6579
Practice Address - Street 1:1205 SE PRO MALL BLVD STE 104
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5423
Practice Address - Country:US
Practice Address - Phone:509-332-6139
Practice Address - Fax:509-332-6579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207Q00000X, 207RC0000X
208000000X, 2084P0800X
WA50-3922261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8891113OtherMEDICARE PTAN
WA50-3922OtherCMS CERTIFICATION