Provider Demographics
NPI:1871575225
Name:NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK
Entity type:Organization
Organization Name:NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/ADMINISTRATIVE DIRECTOR OF FINA
Authorized Official - Prefix:MR
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-815-2263
Mailing Address - Street 1:1000 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3430
Mailing Address - Country:US
Mailing Address - Phone:503-842-4444
Mailing Address - Fax:503-815-2330
Practice Address - Street 1:1000 3RD ST
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3430
Practice Address - Country:US
Practice Address - Phone:503-842-4444
Practice Address - Fax:503-815-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR141177282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000OtherTRICARE
OR381317OtherMEDICARE PTAN
OR005533Medicaid
ORP037001OtherPACIFICSOURCE INS CO.
OR138007000OtherREGENCE BCBS OREGON
KY194212300OtherUS DEPT OF LABOR
ORP057F0OtherPACC HEALTH PLANS
WA0021657OtherWASH DEPT OF L & I
WA3006400Medicaid
WA0021657OtherWASH DEPT OF L & I
OR381317Medicare ID - Type UnspecifiedMEDICARE NW
OR005533Medicaid
OR138007000OtherREGENCE BCBS OREGON