Provider Demographics
NPI:1013064575
Name:PUBLIC HOSPITAL DIST NO 1 SKAGIT
Entity Type:Organization
Organization Name:PUBLIC HOSPITAL DIST NO 1 SKAGIT
Other - Org Name:SKAGIT REGIONAL HEALTH - DARRINGTON FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ISHIZUKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-814-5838
Mailing Address - Street 1:1400 E. KINCAID STREET
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-814-6724
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1190 RIDDLE STREET
Practice Address - Street 2:
Practice Address - City:DARRINGTON
Practice Address - State:WA
Practice Address - Zip Code:98241
Practice Address - Country:US
Practice Address - Phone:360-436-1055
Practice Address - Fax:360-436-0146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QP2300X
WAMTSP.FS.00001468261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2058875Medicaid
WA354488OtherLABOR & INDUSTRIES
WA354488OtherLABOR & INDUSTRIES
WAAB13684Medicare PIN