Provider Demographics
NPI:1871833772
Name:MID-COLUMBIA MEDICAL CENTER
Entity Type:Organization
Organization Name:MID-COLUMBIA MEDICAL CENTER
Other - Org Name:COLUMBIA RIVER WOMEN'S CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE OFFICER CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-296-7273
Mailing Address - Street 1:PO BOX 1520
Mailing Address - Street 2:1810 E. 19TH ST. STE.209
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3388
Mailing Address - Country:US
Mailing Address - Phone:541-296-5657
Mailing Address - Fax:541-298-5199
Practice Address - Street 1:1810 E 19TH ST STE 209
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:541-296-5657
Practice Address - Fax:541-298-5199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR207V00000X
OR383895261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500654923Medicaid
WA2028140Medicaid