MEDICARE: GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	261QR1300X	Rural Health Clinic/Center	HAC.FS.00000186	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	106276	OTHER	WA	L&I
3	135	OTHER	WA	REGENCE PRO
4	106275	OTHER	WA	CRIME VICTIM

General Provider Information

NPI Number	:	1255401683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1

Provider Business Mailing Address
First Line	:	600 E. MAIN STREET
Second Line	:
City	:	ELMA
State	:	WA
Zip	:	98541
Country	:	US
Telephone Number	:	360-346-2222
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 W SIMPSON AVE
Second Line	:
City	:	MCCLEARY
State	:	WA
Zip	:	98557-9657
Country	:	US
Telephone Number	:	360-346-2222
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. RENEE K. JENSEN
Credential	:
Telephone Number	:	360-346-2222

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	04/18/2016

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