Provider Demographics
NPI:1467403329
Name:HERMISTON MEDICAL CENTER
Entity Type:Organization
Organization Name:HERMISTON MEDICAL CENTER
Other - Org Name:FAMILY HEALTH ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:FLAIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:547-567-6434
Mailing Address - Street 1:600 NW 11TH STREET
Mailing Address - Street 2:SUITE E 15
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838
Mailing Address - Country:US
Mailing Address - Phone:541-567-6434
Mailing Address - Fax:541-567-6019
Practice Address - Street 1:600 NW 11TH ST
Practice Address - Street 2:SUITE E 15
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838
Practice Address - Country:US
Practice Address - Phone:541-567-6434
Practice Address - Fax:541-567-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08491207Q00000X
ORMD11635207Q00000X
ORMD14374207Q00000X
ORDO23298207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR083709Medicaid
OR0000WCBCKMedicare ID - Type Unspecified