Provider Demographics
NPI:1629492525
Name:JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Entity Type:Organization
Organization Name:JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Other - Org Name:JEFFERSON HEALTHCARE SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-385-2200
Mailing Address - Street 1:834 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-2443
Mailing Address - Country:US
Mailing Address - Phone:360-385-2200
Mailing Address - Fax:360-379-2282
Practice Address - Street 1:1010 SHERIDAN ST STE 201
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2901
Practice Address - Country:US
Practice Address - Phone:360-385-5444
Practice Address - Fax:360-385-5352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
WAHAC.FS.00000085282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1008579Medicaid
WA3301900Medicaid
WA1008579Medicaid
WAG8865428Medicare Oscar/Certification
WA501323Medicare Oscar/Certification