Provider Demographics
NPI:1366682973
Name:OUR LADY OF LOURDES HEALTH CENTER
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES HEALTH CENTER
Other - Org Name:LOURDES HOSPITALIST PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-543-2483
Mailing Address - Street 1:520 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5257
Mailing Address - Country:US
Mailing Address - Phone:509-547-7704
Mailing Address - Fax:
Practice Address - Street 1:520 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5257
Practice Address - Country:US
Practice Address - Phone:509-547-7704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF LOURDES HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-23
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA113003371208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8855265OtherPTAN
WAG8855265Medicare PIN