Provider Demographics
NPI:1457427528
Name:ST MARY MEDICAL CENTER
Entity Type:Organization
Organization Name:ST MARY MEDICAL CENTER
Other - Org Name:DME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE MANAGEMEN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLUMBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-522-5906
Mailing Address - Street 1:PO BOX 1477
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0312
Mailing Address - Country:US
Mailing Address - Phone:509-522-5900
Mailing Address - Fax:509-522-5578
Practice Address - Street 1:401 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2846
Practice Address - Country:US
Practice Address - Phone:509-522-5900
Practice Address - Fax:509-522-5578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH050332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA08478OtherL & I
WAST4995OtherREGENCE BLUE SHIELD
WA9055955Medicaid
WA1314980001Medicare NSC