Provider Demographics
NPI:1467440602
Name:DEPARTMENT OF SOCIAL DEPT OF SHS DIV OF INSTNS
Entity Type:Organization
Organization Name:DEPARTMENT OF SOCIAL DEPT OF SHS DIV OF INSTNS
Other - Org Name:EASTERN STATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:HELENE
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-565-4131
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:850 MAPLE ST
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-0800
Mailing Address - Country:US
Mailing Address - Phone:509-565-4000
Mailing Address - Fax:509-565-4705
Practice Address - Street 1:850 MAPLE ST
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-0800
Practice Address - Country:US
Practice Address - Phone:509-565-4000
Practice Address - Fax:509-565-4705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG000350700Medicare PIN
WA504004Medicare Oscar/Certification