MEDICARE: PUBLIC HOSPITAL DISTRICT NO 1 OF MASON COUNTY

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	OP00001087	WA
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1700111986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUBLIC HOSPITAL DISTRICT NO 1 OF MASON COUNTY

Provider Business Mailing Address
First Line	:	1812 N 13TH LOOP RD
Second Line	:
City	:	SHELTON
State	:	WA
Zip	:	98584-2169
Country	:	US
Telephone Number	:	360-426-3862
Fax Number	:	360-427-1743

Provider Business Practice Location Address
First Line	:	1812 N 13TH LOOP RD
Second Line	:
City	:	SHELTON
State	:	WA
Zip	:	98584-2169
Country	:	US
Telephone Number	:	360-426-3862
Fax Number	:	360-427-1743

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. GEORGE ROBERT APPEL
Credential	:	CEO
Telephone Number	:	360-427-9556

Provider Enumeration Date	:	10/06/2009
Last Update Date	:	07/15/2011

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1790013373 — PUBLIC HOSPITAL DISTRICT NO 1 OF MASON COUNTY WASHINGTON
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