Provider Demographics
NPI:1699720797
Name:GRANT COUNTY PUBLIC HOSPITAL DISTRICT NO 5
Entity type:Organization
Organization Name:GRANT COUNTY PUBLIC HOSPITAL DISTRICT NO 5
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:509-932-4499
Mailing Address - Street 1:210 GOVERNMENT RD
Mailing Address - Street 2:
Mailing Address - City:MATTAWA
Mailing Address - State:WA
Mailing Address - Zip Code:99349-5116
Mailing Address - Country:US
Mailing Address - Phone:509-932-4499
Mailing Address - Fax:509-932-5363
Practice Address - Street 1:210 GOVERNMENT ROAD
Practice Address - Street 2:
Practice Address - City:MATTAWA
Practice Address - State:WA
Practice Address - Zip Code:99349-0960
Practice Address - Country:US
Practice Address - Phone:509-932-4499
Practice Address - Fax:509-932-5363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363L00000X
WA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7035611OtherDSHS FEE FOR SERVICE
WA67850OtherLABOR & INDUSTRIES
WA501944OtherMEDICARE PTAN
WA7044167Medicaid
WA7406572OtherDSHS MSS
WA7900657OtherDSHS TAKE CHARGE
WA7900657OtherDSHS TAKE CHARGE