Provider Demographics
NPI:1760485221
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:MR
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-108282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA003308004Medicaid
ID003110900Medicaid
000010002128OtherREGENCE BLUE SHIELD OF IDAHO
00620OtherBLUE CROSS OF IDAHO
WA003308004Medicaid
ID1377710Medicare PIN