Provider Demographics
NPI:1417105107
Name:ENUMCLAW REGIONAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:ENUMCLAW REGIONAL HOSPITAL ASSOCIATION
Other - Org Name:ST ELIZABETH HOSPTIAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-680-4005
Mailing Address - Street 1:PO BOX 31001-1475
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-1475
Mailing Address - Country:US
Mailing Address - Phone:888-846-7304
Mailing Address - Fax:253-573-7069
Practice Address - Street 1:1455 BATTERSBY AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3634
Practice Address - Country:US
Practice Address - Phone:888-846-7304
Practice Address - Fax:253-573-7059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH035275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3310406Medicaid
WA50Z335Medicare Oscar/Certification