NPIMap

Organization Active NPI

Tri-State Memorial Hospital

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Lewiston, ID
National Provider Identifier
1386690907
Registry record updated Aug 4, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
License
H-108 Issued in WA
Legal business name
TRI-STATE MEMORIAL HOSPITAL
Practice address
730 21St St
Lewiston, ID 83501-3323
Phone
(208) 746-8280
Fax
(208) 746-8285
NPI assigned
May 25, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 4, 2009

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

Authorized official

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X H-108 WA Primary

Addresses

Primary practice location

730 21St St
Lewiston, ID 83501-3323

Mailing address

1221 Highland Ave.
PO Box 189
Clarkston, WA 98940
Phone (509) 758-5511

Other identifiers 2

IdentifierTypeStateIssuer
003110900MedicaidID
3308004MedicaidWA

Other names 1

  • Tri State Dialysis Center Former legal business name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040911000031 ID Part B Supplier - Clinic/Group Practice 4082502422 Receives reassigned benefits from 28 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lewiston, ID

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

  • Isd Renal Inc
    • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
    • Akron, OH
    • NPI 1407992555

    Member Of

    NPD member

Member organizations 1

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

Locations

730 21st St
Lewiston, ID 83501
Phone (208) 746-8280

Practitioners & affiliated clinicians

Practitioners 9

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

NPI Registry JSON

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

{
    "created_epoch": "1148515200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1249344000000",
    "number": "1386690907",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1221 HIGHLAND AVE.",
            "address_2": "PO BOX 189",
            "city": "CLARKSTON",
            "state": "WA",
            "postal_code": "98940",
            "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": "730 21ST ST",
            "city": "LEWISTON",
            "state": "ID",
            "postal_code": "835013323",
            "telephone_number": "208-746-8280",
            "fax_number": "208-746-8285"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRI-STATE MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-25",
        "last_updated": "2009-08-04",
        "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",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": "WA",
            "license": "H-108",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003110900",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3308004",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tri State Dialysis Center",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Lewiston, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 4, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.