Provider Demographics
NPI:1578635660
Name:MID-COLUMBIA SURGICAL SPECIALISTS
Entity Type:Organization
Organization Name:MID-COLUMBIA SURGICAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTZLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-296-6101
Mailing Address - Street 1:1810 E 19TH ST STE 225
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3388
Mailing Address - Country:US
Mailing Address - Phone:541-296-6101
Mailing Address - Fax:541-296-0025
Practice Address - Street 1:1810 E 19TH ST STE 225
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3388
Practice Address - Country:US
Practice Address - Phone:541-296-6101
Practice Address - Fax:541-296-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7023476Medicaid
OR198150Medicaid
OR198150Medicaid
CP7688Medicare PIN
WA7023476Medicaid