Provider Demographics
NPI:1154351336
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 1:1620 E 12TH ST
Mailing Address - Street 2:PO BOX 1520
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058
Mailing Address - Country:US
Mailing Address - Phone:541-296-9151
Mailing Address - Fax:541-296-9156
Practice Address - Street 1:1620 E 12TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058
Practice Address - Country:US
Practice Address - Phone:541-296-9151
Practice Address - Fax:541-296-9156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 1041C0700X, 207Q00000X, 208000000X, 261QR1300X, 363A00000X, 363LF0000X
OR261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1003624Medicaid
OR218112Medicaid
OR383996Medicare Oscar/Certification
OR218112Medicaid