NPIMap

Organization Active NPI

Grays Harbor County Public Hospital District No 1

Doing business as Summit Pacific Health Clinic

  • Rural Health Clinic/Center
  • Elma, WA
National Provider Identifier
1083202907
Registry record updated May 23, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Doing business as
Summit Pacific Health Clinic
Practice address
579 E Main St
BLDG 2
Elma, WA 98541
Phone
(360) 346-2222
Fax
(360) 346-2192
NPI assigned
Jan 6, 2021
Last updated
May 23, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO 1As reported in NPPES

NPPES NPI Registry

Updated by the provider on May 23, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lynn Fifield
Title
Medical Staff Services Director
Phone
(360) 346-2222

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

579 E Main St
BLDG 2
Elma, WA 98541

Mailing address

Grays Harbor Public Hospital District No 1
600 E Main Street
Elma, WA 98541
Phone (360) 346-2222

Other names 1

  • Summit Pacific Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031226000146 WA Part B Supplier - Clinic/Group Practice 9032017256 Receives reassigned benefits from 158 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Elma, WA; McCleary, WA
O20210316001628 WA Part A Provider - Rural Health Clinic 9032017256 Practice locations: Elma, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1083202907. Details of each certification follow.

Rural health clinic certification: CCN 508596

Legal name
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Doing business as
SUMMIT PACIFIC HEALTH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 18, 2023
Last certification
Dec 18, 2023
Ownership / control type
2B
Organization structure
OtherNon-profit
Incorporated
Jan 1, 1982 in WA
Enrollment address
579 E Main St
Elma, WA 98541-9560
Related CCNs
501304

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
50D2211457Summit Pacific Health Clinic579 E Main St, Elma, WA 98541Certificate of waiverApr 4, 2028

National Provider Directory

National Provider Directory
Part of
Grays Harbor County Public

Locations

575 E Main St
Unit 2
Elma, WA 98541
Phone (360) 482-2139

579 E Main St
Elma, WA 98541
Phone (360) 346-2222

579 E Main St
Bldg 2
Elma, WA 98541
Phone (360) 346-2222

610 E Main St
Elma, WA 98541
Phone (360) 346-2222

Ownership & related parties

All disclosed owners & managing parties 5

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kenneth Dietrich Individual Corporate OfficerChief Medical Officer Mar 24, 2016
Blake Rose Individual Corporate OfficerChief Administrative Officer Jan 1, 2021
W-2 Managing EmployeeChief Administrative Officer Jan 1, 2021
Joshua Martin Individual Corporate OfficerCeo Apr 10, 2017
James Hansen Individual Corporate OfficerCfo May 1, 2018
Grays Harbor County Public Hospital District No 1 Organization, Elma, WA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Feb 1, 2021 100%

Owners & managing parties with NPI records 6

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Summit Pacific Medical Center - Swing Bed UnitElma, WA, CCN 50Z304 Hospital Operational/Managerial Control (100%) Feb 18, 2013
Summit Pacific Medical CenterElma, WA, CCN 501304 Hospital Operational/Managerial Control (5%) Jul 1, 1985
McCleary Healthcare ClinicMcCleary, WA, CCN 503998 Rural health clinic 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 May 17, 2010
May 17, 2010
Summit Pacific Healthcare ClinicElma, WA, CCN 508560 Rural health clinic Operational/Managerial Control Feb 18, 2013

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 4

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 157

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 157

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1609891200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1684800000000",
    "number": "1083202907",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "GRAYS HARBOR PUBLIC HOSPITAL DISTRICT NO 1",
            "address_2": "600 E MAIN STREET",
            "city": "ELMA",
            "state": "WA",
            "postal_code": "98541",
            "telephone_number": "360-346-2222",
            "fax_number": "360-346-2192"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "579 E MAIN ST",
            "address_2": "BLDG 2",
            "city": "ELMA",
            "state": "WA",
            "postal_code": "98541",
            "telephone_number": "360-346-2222",
            "fax_number": "360-346-2192"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO 1",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO 1",
        "enumeration_date": "2021-01-06",
        "last_updated": "2023-05-23",
        "certification_date": "2023-05-12",
        "status": "A",
        "authorized_official_last_name": "FIFIELD",
        "authorized_official_first_name": "LYNN",
        "authorized_official_title_or_position": "MEDICAL STAFF SERVICES DIRECTOR",
        "authorized_official_telephone_number": "360-346-2222"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Summit Pacific Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Summit Pacific Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Elma, WA

Sources for this page

Verify at the official NPI Registry.