NPIMap

Organization Active NPI

Tri-State Memorial Hospital

  • Medicare Defined Swing Bed Hospital Unit
  • Clarkston, WA
National Provider Identifier
1174697353
Registry record updated Sep 21, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
License
H108 Issued in WA
Legal business name
TRI-STATE MEMORIAL HOSPITAL
Practice address
1221 Highland Avenue
Clarkston, WA 99403
Phone
(509) 758-5511
Fax
(509) 751-9406
NPI assigned
Nov 20, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 21, 2012

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

Authorized official

Name
Alex C Town
Title
Cfo
Phone
(509) 758-4667

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X H108 WA Primary

Addresses

Primary practice location

1221 Highland Avenue
Clarkston, WA 99403

Mailing address

PO Box 189
Clarkston, WA 99403
Phone (509) 758-5511

Other identifiers 2

IdentifierTypeStateIssuer
3308004MedicaidWA
806933500MedicaidID

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070911000972 WA Part A Provider - Critical Access Hospital 4082502422 Practice locations: Clarkston, WA

Hospital certification: CCN 50Z332

Legal name
TRI-STATE MEMORIAL HOSPITAL
Organization structure
CorporationNon-profit
Incorporated
Nov 6, 1947 in WA
Enrollment address
1221 Highland Ave
Clarkston, WA 99403-2829
Hospital Swing-Bed Unit

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

Other NPIs with the same Medicare PAC ID 2

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

National Provider Directory

National Provider Directory
Tax ID family
Tri-State Hosp Supplier3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
John Seeh Individual Corporate Director May 1, 2012
Donald J. Wee Individual Corporate OfficerCeo Oct 5, 2009
W-2 Managing Employee Oct 5, 2009
Eddie Wayne Day Individual Corporate Director Jun 24, 2004
Donald McQuary Individual Corporate Director Jun 24, 2004
Debra Ausman Individual Corporate Director May 1, 2012
Dawn Larae Merrill Individual Corporate Director Jun 24, 2004
Sandy K Blume Individual W-2 Managing Employee May 1, 2012
Richard Flerchinger Individual Corporate Director Jun 24, 2004
Julie L Leonard Individual Corporate OfficerCfo May 1, 2019
W-2 Managing EmployeeCfo May 1, 2019
Daniel Klaveano Individual Corporate Director May 1, 2012
Scott Arnone Individual Corporate Director Jun 24, 2004
Michael Martin Individual Corporate Director Jun 24, 2004

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1163980800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1348185600000",
    "number": "1174697353",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 189",
            "city": "CLARKSTON",
            "state": "WA",
            "postal_code": "99403",
            "telephone_number": "509-758-5511",
            "fax_number": "509-751-9406"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1221 HIGHLAND AVENUE",
            "city": "CLARKSTON",
            "state": "WA",
            "postal_code": "99403",
            "telephone_number": "509-758-5511",
            "fax_number": "509-751-9406"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRI-STATE MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-20",
        "last_updated": "2012-09-21",
        "status": "A",
        "authorized_official_last_name": "TOWN",
        "authorized_official_first_name": "ALEX",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "509-758-4667"
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "WA",
            "license": "H108",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3308004",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806933500",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Clarkston, WA

Sources for this page

Verify at the official NPI Registry.