Provider Demographics
NPI:1053409599
Name:MID-COLUMBIA MEDICAL CENTER
Entity type:Organization
Organization Name:MID-COLUMBIA MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SERVICE AREA PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-261-4405
Mailing Address - Street 1:1700 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3317
Mailing Address - Country:US
Mailing Address - Phone:541-296-7668
Mailing Address - Fax:541-296-1111
Practice Address - Street 1:1700 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3317
Practice Address - Country:US
Practice Address - Phone:541-296-1111
Practice Address - Fax:541-296-7619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2008493Medicaid
OR070115Medicaid