NPIMap

Organization Active NPI

Public Hospital District No 1 of Mason County

Doing business as MGH Family Health Ankle & Foot Clinic

  • Rural Health Clinic/Center
  • Shelton, WA
National Provider Identifier
1164876629
Registry record updated Apr 14, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PUBLIC HOSPITAL DISTRICT NO 1 OF MASON COUNTY
Doing business as
MGH Family Health Ankle & Foot Clinic
Practice address
1812 N 13TH Loop Rd
Shelton, WA 98584-2169
Phone
(360) 426-3862
NPI assigned
Apr 20, 2016
Last updated
Apr 14, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 14, 2017

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

Authorized official

Name
Mr. Eric Moll
Title
Ceo
Phone
(360) 427-9556

Specialties & licenses 1

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

Addresses

Primary practice location

1812 N 13TH Loop Rd
Shelton, WA 98584-2169

Mailing address

1812 N 13TH Loop Rd
Shelton, WA 98584-2169
Phone (360) 426-3862

Other names 1

  • MGH Family Health Ankle & Foot Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160706001095 WA Part A Provider - Rural Health Clinic 6608932116 Practice locations: Shelton, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1164876629. Details of each certification follow.

Rural health clinic certification: CCN 508571

Legal name
PUBLIC HOSPITAL DISTRICT NO 1 OF MASON COUNTY
Doing business as
MASON GENERAL HOSPITAL FAMILY HEALTH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 11, 2016
Last certification
Aug 11, 2016
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Aug 19, 2003 in WA
Enrollment address
1812 N 13TH Loop Rd
Shelton, WA 98584-2169
Related CCNs
501336

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

Other NPIs with the same Medicare PAC ID 1

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

National Provider Directory

National Provider Directory
Tax ID family
Public Hosp Dist 1 of Mason18 organizations share this tax ID, including this one

Other organizations with this tax ID 17

Organizations that report the same tax identification number in the National Provider Directory.

View all 17

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Eric C Moll Individual Corporate OfficerCeo Apr 1, 2013
Stephen Leslie Individual W-2 Managing EmployeeChief Financial Officer Dec 1, 2022
Public Hospital District No 1 of Mason County Organization, Shelton, WA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Nov 10, 2009 100%

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1461110400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1492128000000",
    "number": "1164876629",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1812 N 13TH LOOP RD",
            "city": "SHELTON",
            "state": "WA",
            "postal_code": "985842169",
            "telephone_number": "360-426-3862"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1812 N 13TH LOOP RD",
            "city": "SHELTON",
            "state": "WA",
            "postal_code": "985842169",
            "telephone_number": "360-426-3862"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PUBLIC HOSPITAL DISTRICT NO 1 OF MASON COUNTY",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-04-20",
        "last_updated": "2017-04-14",
        "status": "A",
        "authorized_official_last_name": "MOLL",
        "authorized_official_first_name": "ERIC",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "360-427-9556",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MGH Family Health Ankle & Foot Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shelton, WA

Sources for this page

Verify at the official NPI Registry.