Provider Demographics
NPI:1164735478
Name:MID-COLUMBIA MEDICAL CENTER
Entity Type:Organization
Organization Name:MID-COLUMBIA MEDICAL CENTER
Other - Org Name:GORGE UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-296-7273
Mailing Address - Street 1:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-0000
Mailing Address - Country:US
Mailing Address - Phone:541-296-2201
Mailing Address - Fax:541-296-1237
Practice Address - Street 1:1805 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-0000
Practice Address - Country:US
Practice Address - Phone:541-296-2201
Practice Address - Fax:541-296-1237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500630716Medicaid
WA2008645Medicaid