Provider Demographics
NPI:1407887052
Name:MID-COLUMBIA MEDICAL CENTER
Entity Type:Organization
Organization Name:MID-COLUMBIA MEDICAL CENTER
Other - Org Name:WATER'S EDGE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE OFFICER CEO
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 1:551 LONE PINE BLVD
Mailing Address - Street 2:PO BOX 1520
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058
Mailing Address - Country:US
Mailing Address - Phone:541-506-6920
Mailing Address - Fax:541-296-5451
Practice Address - Street 1:551 LONE PINE BLVD
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058
Practice Address - Country:US
Practice Address - Phone:541-506-6920
Practice Address - Fax:541-296-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218103Medicaid
OR276258Medicaid
WA1009681Medicaid
ORR0000WFBLKMedicare PIN