NPIMap

Organization Active NPI

Privia Medical Group Washington, PLLC

  • Rural Health Clinic/Center
  • Walla Walla, WA
National Provider Identifier
1346441979
Registry record updated Oct 6, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
FX00058422 Issued in WA
Legal business name
PRIVIA MEDICAL GROUP WASHINGTON, PLLC
Practice address
55 W Tietan St
Walla Walla, WA 99362-4445
Phone
(509) 525-3720
Fax
(509) 522-1292
NPI assigned
May 30, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 6, 2023

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

Authorized official

Name
Kevin J Michelson
Title
Ceo
Phone
(509) 525-3720

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X FX00058422 WA Primary

Addresses

Primary practice location

55 W Tietan St
Walla Walla, WA 99362-4445

Mailing address

55 W Tietan St
Walla Walla, WA 99362-4445
Phone (509) 525-3720

Other identifiers 1

IdentifierTypeStateIssuer
7086820MedicaidWA

Other names 1

  • Walla Walla Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110111000930 WA Part A Provider - Rural Health Clinic 2264320837 Practice locations: Walla Walla, WA

Rural health clinic certification: CCN 503846

Legal name
PRIVIA MEDICAL GROUP WASHINGTON PLLC
Doing business as
WALLA WALLA CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 17, 1997
Last certification
Mar 11, 2019
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Dec 24, 1970 in WA
Enrollment address
55W Tietan St
Walla Walla, WA 99362-4445

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

National Provider Directory
Tax ID family
Walla Walla Clinic Surg7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

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

Locations

55 W Tietan St
Bldg C
Walla Walla, WA 99362

Ownership & related parties

All disclosed owners & managing parties 24

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

NameRoleSinceShare
Susan E Thompson Individual General Partnership Interest Nov 19, 2007
Erik C Gryler Individual General Partnership Interest Nov 19, 2007
Clinton Streifling Individual W-2 Managing EmployeeDirector of Business Services Jul 17, 1997
Scott T Fry Individual General Partnership Interest Nov 19, 2007
William Wagner Individual General Partnership Interest Nov 19, 2007
Eric J Jauhiainen Individual General Partnership Interest Nov 19, 2007
Joseph J Wujek Individual General Partnership Interest Nov 19, 2007
Philip R Morgan Individual General Partnership Interest Nov 19, 2007
Michael J Wilcox Individual General Partnership Interest Nov 19, 2007
Eric M Ball Individual General Partnership Interest Nov 19, 2007
Alison E Kirby Individual General Partnership Interest Nov 19, 2007
John G Sislow Individual General Partnership Interest Nov 19, 2007
Joanne M Schmitz Individual General Partnership Interest Nov 19, 2007
Karen Henderson Individual General Partnership Interest Nov 19, 2007
Kevin Michelson Individual Corporate OfficerCeo Sep 24, 2012
W-2 Managing EmployeeCeo Sep 24, 2012
Tammy Fowler Individual W-2 Managing Employee Jul 17, 1997
Daniel F Kaminsky Individual General Partnership Interest Nov 19, 2007
Julie Wuest Individual General Partnership Interest Nov 19, 2007
Theodore J Bergstrom Individual General Partnership Interest Nov 19, 2007
Jeffrey C Stiles Individual General Partnership Interest Nov 19, 2007
Luisa S Scholar Individual General Partnership Interest Nov 19, 2007
Robert Carmody Individual General Partnership Interest Nov 19, 2007
Timothy D Barry Individual General Partnership Interest Nov 19, 2007
Patricia M McIlvaine Individual General Partnership Interest Nov 19, 2007

Owners & managing parties with NPI records 7

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

Practitioners & affiliated clinicians

Practitioners 75

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

View all 75

NPI Registry JSON

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

{
    "created_epoch": "1180483200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1696550400000",
    "number": "1346441979",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "55 W TIETAN ST",
            "city": "WALLA WALLA",
            "state": "WA",
            "postal_code": "993624445",
            "telephone_number": "509-525-3720",
            "fax_number": "509-522-1292"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "55 W TIETAN ST",
            "city": "WALLA WALLA",
            "state": "WA",
            "postal_code": "993624445",
            "telephone_number": "509-525-3720",
            "fax_number": "509-522-1292"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIVIA MEDICAL GROUP WASHINGTON, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-30",
        "last_updated": "2023-10-06",
        "certification_date": "2023-10-06",
        "status": "A",
        "authorized_official_last_name": "MICHELSON",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "509-525-3720"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "WA",
            "license": "FX00058422",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7086820",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Walla Walla Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Walla Walla Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Walla Walla, WA

Sources for this page

Verify at the official NPI Registry.