Provider Demographics
NPI:1528383940
Name:MID-COLUMBIA MEDICAL CENTER
Entity Type:Organization
Organization Name:MID-COLUMBIA MEDICAL CENTER
Other - Org Name:ADVENTIST HEALTH COLUMBIA GORGE
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:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058
Mailing Address - Country:US
Mailing Address - Phone:541-506-6520
Mailing Address - Fax:541-506-6516
Practice Address - Street 1:1935 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3392
Practice Address - Country:US
Practice Address - Phone:541-506-6520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QR1300X, 261QR1300X
1041C0700X, 207Q00000X, 207RE0101X, 208000000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500628255Medicaid
WA2008485Medicaid
OR500632165Medicaid
OR388506Medicare Oscar/Certification
ORR0000WFBLKMedicare PIN