Basic Information
| Provider Information | |||||||||
| NPI: | 1619086766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRANT COUNTY PUBLIC HOSPITAL DISTRICT 1 | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAMARITAN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S COOLIDGE ST | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988371872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097939715 | ||||||||
| FaxNumber: | 5097643244 | ||||||||
| Practice Location | |||||||||
| Address1: | 1550 S PIONEER WAY STE 115 | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988374618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097939713 | ||||||||
| FaxNumber: | 5097643244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5097939710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAMARITAN HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1014658 | 05 | WA | MEDICAID | 7063415 | 05 | WA | MEDICAID | 7109929 | 05 | WA | MEDICAID |