Provider Demographics
NPI:1053873919
Name:NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK
Entity type:Organization
Organization Name:NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-815-2263
Mailing Address - Street 1:PO BOX 888860
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90088-8860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 SE JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:OR
Practice Address - Zip Code:97378-1924
Practice Address - Country:US
Practice Address - Phone:503-842-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-01
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005533Medicaid