Healthcare Provider Details

I. General information

NPI: 1366809048
Provider Name (Legal Business Name): MID-COLUMBIA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 E. 19TH ST. #225
THE DALLES OR
97058
US

IV. Provider business mailing address

PO BOX 1520
THE DALLES OR
97058
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-6101
  • Fax: 541-296-0025
Mailing address:
  • Phone: 541-298-7971
  • Fax: 541-296-6431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KYLE KING
Title or Position: SERVICE AREA PRESIDENT
Credential:
Phone: 503-261-4405