Healthcare Provider Details

I. General information

NPI: 1598814352
Provider Name (Legal Business Name): TRI-STATE MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 HIGHLAND AVE
CLARKSTON WA
99403-2829
US

IV. Provider business mailing address

1221 HIGHLAND AVE
CLARKSTON WA
99403-2829
US

V. Phone/Fax

Practice location:
  • Phone: 509-758-5511
  • Fax: 509-751-9406
Mailing address:
  • Phone: 509-758-5511
  • Fax: 509-751-9406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License NumberH-108
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALEX C TOWN
Title or Position: CFO
Credential:
Phone: 509-758-4667