Provider Demographics
NPI:1598814352
Name:TRI-STATE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:TRI-STATE MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:C
Authorized Official - Last Name:TOWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-758-4667
Mailing Address - Street 1:1221 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2829
Mailing Address - Country:US
Mailing Address - Phone:509-758-5511
Mailing Address - Fax:509-751-9406
Practice Address - Street 1:1221 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2829
Practice Address - Country:US
Practice Address - Phone:509-758-5511
Practice Address - Fax:509-751-9406
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-10
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207RN0300X, 208600000X, 208800000X
WAH-108282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8K289OtherBLUE CROSS OF IDAHO
WA007032733Medicaid
ID003111000Medicaid
WA0082114OtherLABOR AND INDUSTRIES
ID000010142729OtherREGENCE BLUE SHEILD
WA007032733Medicaid
ID003111000Medicaid
ID1377310Medicare Oscar/Certification