NPIMap

Organization Active NPI

Department of Social Dept of SHS Div of Instns

Doing business as Eastern State Hospital

  • Psychiatric Hospital
  • Medical Lake, WA
National Provider Identifier
1467440602
Registry record updated Mar 10, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric HospitalTaxonomy code 283Q00000X
Legal business name
DEPARTMENT OF SOCIAL DEPT OF SHS DIV OF INSTNS
Doing business as
Eastern State Hospital
Practice address
850 Maple St
Medical Lake, WA 99022-0800
Phone
(509) 565-4000
Fax
(509) 565-4705
NPI assigned
Oct 12, 2005
Last updated
Mar 10, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 10, 2022

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

Authorized official

Name
Jessica Helene Graham
Title
Director, Revenue Cycle
Phone
(509) 565-4131

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital 283Q00000X Primary

Addresses

Primary practice location

850 Maple St
Medical Lake, WA 99022-0800

Mailing address

PO Box 800
850 Maple St
Medical Lake, WA 99022-0800
Phone (509) 565-4000

Other names 1

  • Eastern State Hospital Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040213000028 WA Part B Supplier - Clinic/Group Practice 9133013725 Receives reassigned benefits from 68 practitioners
Practice locations: Medical Lake, WA
O20060505000766 WA Part A Provider - Hospital 9133013725 Practice locations: Medical Lake, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1467440602. Details of each certification follow.

Hospital certification: CCN 504004

Legal name
DEPARTMENT OF SOCIAL DEPT OF SHS DIV OF INSTNS
Doing business as
EASTERN STATE HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Psychiatric
Participating since
Jul 1, 1966
Last certification
Jun 15, 2016
Beds
287
Ownership / control type
State
Organization structure
OtherNon-profit
Enrollment address
850 Maple St
Medical Lake, WA 99022-0800
Other Hospital Practice Location
Hospital subgroups
Psychiatric

Care Compare: Hospital

Medicare Care Compare
Listed as
Eastern State HospitalCCN 504004 · All quality measures
Type
Psychiatric
Ownership
Government - State
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
No

National Provider Directory

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
Patty Hendrix Individual W-2 Managing EmployeeProgram Manager Jul 1, 2014 33%
Mark Kettner Individual Corporate OfficerCeo Apr 1, 2018 50%
Corporate DirectorCeo Apr 1, 2018 50%
W-2 Managing EmployeeCeo Apr 1, 2018 34%
Operational/Managerial ControlCeo Apr 1, 2018 50%
Ronda D Kenney Individual Corporate OfficerCoo Jul 1, 2014 50%
W-2 Managing EmployeeCoo Jul 1, 2014 33%
Operational/Managerial ControlCoo Jul 1, 2014 50%

Practitioners & affiliated clinicians

Practitioners 198

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 198

NPI Registry JSON

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

{
    "created_epoch": "1129075200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1646870400000",
    "number": "1467440602",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 800",
            "address_2": "850 MAPLE ST",
            "city": "MEDICAL LAKE",
            "state": "WA",
            "postal_code": "990220800",
            "telephone_number": "509-565-4000",
            "fax_number": "509-565-4705"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "850 MAPLE ST",
            "city": "MEDICAL LAKE",
            "state": "WA",
            "postal_code": "990220800",
            "telephone_number": "509-565-4000",
            "fax_number": "509-565-4705"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEPARTMENT OF SOCIAL DEPT OF SHS DIV OF INSTNS",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-12",
        "last_updated": "2022-03-10",
        "certification_date": "2022-02-28",
        "status": "A",
        "authorized_official_last_name": "GRAHAM",
        "authorized_official_first_name": "JESSICA",
        "authorized_official_middle_name": "HELENE",
        "authorized_official_title_or_position": "DIRECTOR, REVENUE CYCLE",
        "authorized_official_telephone_number": "509-565-4131"
    },
    "taxonomies": [
        {
            "code": "283Q00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Hospital",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Eastern State Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Eastern State Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Medical Lake, WA

Sources for this page

Verify at the official NPI Registry.