Provider Demographics
NPI:1841405206
Name:MID-COLUMBIA FAMILY PHYSICIANS,P.S.
Entity Type:Organization
Organization Name:MID-COLUMBIA FAMILY PHYSICIANS,P.S.
Other - Org Name:MID COLUMBIA FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:R
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LABERGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-493-2133
Mailing Address - Street 1:PO BOX 1519
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-1519
Mailing Address - Country:US
Mailing Address - Phone:509-493-2133
Mailing Address - Fax:509-495-9538
Practice Address - Street 1:875 ROCK CRK DRIVE SW
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:WA
Practice Address - Zip Code:98648-0875
Practice Address - Country:US
Practice Address - Phone:509-427-4212
Practice Address - Fax:509-427-4955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600416746207Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7065576Medicaid
WA7033376Medicaid
WA000680900Medicare PIN
WA7033376Medicaid