Basic Information
Provider Information | |||||||||
NPI: | 1053981910 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GRANT COUNTY PUBLIC HOSPITAL DISTRICT 1 | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 660 S COOLIDGE ST | ||||||||
Address2: |   | ||||||||
City: | MOSES LAKE | ||||||||
State: | WA | ||||||||
PostalCode: | 988371872 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5097939715 | ||||||||
FaxNumber: | 5097643244 | ||||||||
Practice Location | |||||||||
Address1: | 801 E WHEELER RD | ||||||||
Address2: |   | ||||||||
City: | MOSES LAKE | ||||||||
State: | WA | ||||||||
PostalCode: | 988371820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5097655606 | ||||||||
FaxNumber: | 5097643244 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2021 | ||||||||
LastUpdateDate: | 07/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ENGELBERT | ||||||||
AuthorizedOfficialFirstName: | HOLLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACT REIMBURSEMENT ANALYST | ||||||||
AuthorizedOfficialTelephone: | 5097939634 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GRANT COUNTY PUBLIC HOSPITAL DISTRICT 1 | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
No ID Information.