Provider Demographics
NPI:1407226590
Name:TRI CITY ORTHOPAEDIC CLINIC, PSC
Entity Type:Organization
Organization Name:TRI CITY ORTHOPAEDIC CLINIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:MERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-460-5588
Mailing Address - Street 1:6703 W RIO GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2623
Mailing Address - Country:US
Mailing Address - Phone:509-460-5588
Mailing Address - Fax:509-783-5438
Practice Address - Street 1:6699 W RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3301
Practice Address - Country:US
Practice Address - Phone:509-460-5588
Practice Address - Fax:509-783-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601824458207X00000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7085939Medicaid
WACG4772OtherRR MEDICARE
WA116832OtherL&I
WAGAB01868Medicare PIN