Provider Demographics
NPI:1194747774
Name:KITTITAS COUNTY PUBLIC HOSPITAL DIST 1
Entity type:Organization
Organization Name:KITTITAS COUNTY PUBLIC HOSPITAL DIST 1
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CBO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-933-8771
Mailing Address - Street 1:P.O. BOX 799
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926
Mailing Address - Country:US
Mailing Address - Phone:509-962-5060
Mailing Address - Fax:509-674-5034
Practice Address - Street 1:201 ALPHA WAY
Practice Address - Street 2:
Practice Address - City:CLE ELUM
Practice Address - State:WA
Practice Address - Zip Code:98922-1045
Practice Address - Country:US
Practice Address - Phone:509-674-5331
Practice Address - Fax:509-674-5034
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KITTITAS COUNTY PUBLIC HOSPITAL DIST 1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-24
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA508541Medicare Oscar/Certification
WA508541Medicare ID - Type UnspecifiedCEFMC