NPIMap

Organization Active NPI

Public Hospital District No 1 of Mason County Washington

Doing business as Mason General Hospital Surgery Clinic

  • Surgery Physician
  • Shelton, WA
National Provider Identifier
1639339666
Registry record updated Sep 19, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
MD00045973 Issued in WA
Legal business name
PUBLIC HOSPITAL DISTRICT NO 1 OF MASON COUNTY WASHINGTON
Doing business as
Mason General Hospital Surgery Clinic
Practice address
1710 N 13TH Loop Rd
Shelton, WA 98584-2166
Phone
(360) 426-4142
Fax
(360) 427-5772
NPI assigned
Jun 12, 2008
Last updated
Sep 19, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 19, 2013

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

Authorized official

Name
Mr. Eric Moll, CEO
Title
Chief Executive Officer
Phone
(360) 427-9554

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery Physician 208600000X MD00045973 WA Primary

Addresses

Primary practice location

1710 N 13TH Loop Rd
Shelton, WA 98584-2166

Mailing address

1710 N 13TH Loop Rd
Shelton, WA 98584-2166
Phone (360) 426-4142

Other identifiers 1

IdentifierTypeStateIssuer
7143456MedicaidWA

Other names 1

  • Mason General Hospital Surgery Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050106000705 WA Part A Provider - Critical Access Hospital 0345139275 Receives reassigned benefits from 52 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Shelton, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639339666. Details of each certification follow.

Hospital certification: CCN 501336

Legal name
PUBLIC HOSPITAL DISTRICT NO 1 OF MASON COUNTY
Doing business as
MASON GENERAL HOSPITAL & FAMILY OF CLINICS
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Jan 1, 2005
Last certification
Jan 22, 2016
Beds
25
Ownership / control type
Hospital district or authority
Organization structure
GovernmentNon-profit
Enrollment address
901 Mt View Dr
Shelton, WA 98584-4401
Other Hospital Practice Location

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

Other NPIs on the same Medicare enrollment 4

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Mason General Hospital & Family of ClinicsCCN 501336 · All quality measures
Overall star rating
2 of 5
Type
Critical Access Hospitals
Ownership
Government - Hospital District or Authority
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Member organizations 2

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

Locations

1710 N 13th Loop Rd
Shelton, WA 98584
Phone (360) 426-4142

Ownership & related parties

All disclosed owners & managing parties 4

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 Director Jul 1, 2004
W-2 Managing Employee Jul 1, 2004
Stephen Leslie Individual W-2 Managing Employee Dec 31, 2022
Gayle Weston Individual Corporate Officer Nov 1, 2021
Darrin Moody Individual Corporate Officer Nov 1, 2021

Practitioners & affiliated clinicians

Practitioners 1

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.

Affiliated clinicians 255

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

View all 255

NPI Registry JSON

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

{
    "created_epoch": "1213228800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1379548800000",
    "number": "1639339666",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1710 N 13TH LOOP RD",
            "city": "SHELTON",
            "state": "WA",
            "postal_code": "985842166",
            "telephone_number": "360-426-4142",
            "fax_number": "360-427-5772"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1710 N 13TH LOOP RD",
            "city": "SHELTON",
            "state": "WA",
            "postal_code": "985842166",
            "telephone_number": "360-426-4142",
            "fax_number": "360-427-5772"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PUBLIC HOSPITAL DISTRICT NO 1 OF MASON COUNTY WASHINGTON",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-06-12",
        "last_updated": "2013-09-19",
        "status": "A",
        "authorized_official_last_name": "MOLL",
        "authorized_official_first_name": "ERIC",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "360-427-9554",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CEO"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "WA",
            "license": "MD00045973",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7143456",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mason General Hospital Surgery Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shelton, WA

Sources for this page

Verify at the official NPI Registry.