NPIMap

Organization Active NPI

Grays Harbor County Public Hospital District No 1

Doing business as Summit Pacific Medical Center

  • Medicare Defined Swing Bed Hospital Unit
  • Elma, WA
National Provider Identifier
1750554366
Registry record updated Jan 24, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
License
H-186 Issued in WA
Legal business name
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Doing business as
Summit Pacific Medical Center
Practice address
600 E. Main Street
Elma, WA 98541
Phone
(360) 495-3244
Fax
(360) 495-4274
NPI assigned
Apr 4, 2008
Last updated
Jan 24, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 24, 2013

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

Authorized official

Name
Ms. Renee K Jensen
Title
Ceo
Phone
(360) 495-3244

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X H-186 WA Primary

Addresses

Primary practice location

600 E. Main Street
Elma, WA 98541

Mailing address

600 E. Main Street
Elma, WA 98541
Phone (360) 495-3244

Other identifiers 10

IdentifierTypeStateIssuer
QMXPR0048030OtherWAMOLINA H/O
GR6577OtherWAREGENCE BLUE SHEILD
7257108MedicaidWA
18091OtherWAL&I ER FACILITY
8903272OtherWACRIME VICTIMS
135OtherWAPREMERA
3147709MedicaidWA
18090OtherWAL&I ER DOC NUMBER
G000800088OtherWAMEDICARE PRO FEE
CD1667OtherWARAILROAD MEDICARE

Other names 1

  • Summit Pacific Medical Center Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031226000146 WA Part B Supplier - Clinic/Group Practice 9032017256 Receives reassigned benefits from 158 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Elma, WA; McCleary, WA
O20080422000913 WA Part A Provider - Critical Access Hospital 9032017256 Practice locations: Elma, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1750554366. Details of each certification follow.

Hospital certification: CCN 50Z304

Legal name
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Doing business as
SUMMIT PACIFIC MEDICAL CENTER - SWING BED UNIT
Organization structure
OtherNon-profit
Incorporated
Jan 1, 1982 in WA
Enrollment address
600 E Main St
Elma, WA 98541-9560
Hospital Swing-Bed Unit

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

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 5

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

National Provider Directory

National Provider Directory

Locations

610 E Main St
Elma, WA 98541
Phone (360) 346-2222

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Georgette Hiles Individual Corporate DirectorCommissioner Jan 1, 2020 5%
Kenneth Dietrich Individual Corporate OfficerChief Medical Officer Mar 22, 2018 75%
Lynn Fifield Individual W-2 Managing EmployeeMedical Staff Program Coordinator Mar 10, 2015 5%
Andrew T Hooper Individual Corporate DirectorBoard Member Position 1 Jan 1, 2008
Joshua Martin Individual Corporate Officer Apr 10, 2017 75%
Cheryl J Cornwell Individual Corporate OfficerChief Financial Officer May 1, 2025
Gary Thumser Individual Corporate DirectorBoard Member Position 3 Jan 1, 2014
Grays Harbor County Public Hospital District No 1 Organization, Elma, WA Non-profit Operational/Managerial Control Feb 18, 2013 100%

Owners & managing parties with NPI records 6

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

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Summit Pacific Medical CenterElma, WA, CCN 501304 Hospital Operational/Managerial Control (5%) Jul 1, 1985
McCleary Healthcare ClinicMcCleary, WA, CCN 503998 Rural health clinic 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 May 17, 2010
May 17, 2010
Summit Pacific Healthcare ClinicElma, WA, CCN 508560 Rural health clinic Operational/Managerial Control Feb 18, 2013
Summit Pacific Health ClinicElma, WA, CCN 508596 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Feb 1, 2021

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 4

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 18

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 18

Affiliated clinicians 2

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": "1207267200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1358985600000",
    "number": "1750554366",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "600 E. MAIN STREET",
            "city": "ELMA",
            "state": "WA",
            "postal_code": "98541",
            "telephone_number": "360-495-3244",
            "fax_number": "360-495-4274"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 E. MAIN STREET",
            "city": "ELMA",
            "state": "WA",
            "postal_code": "98541",
            "telephone_number": "360-495-3244",
            "fax_number": "360-495-4274"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO 1",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-04",
        "last_updated": "2013-01-24",
        "status": "A",
        "authorized_official_last_name": "JENSEN",
        "authorized_official_first_name": "RENEE",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "360-495-3244",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "WA",
            "license": "H-186",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MOLINA H/O",
            "identifier": "QMXPR0048030",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHEILD",
            "identifier": "GR6577",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7257108",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "L&I ER FACILITY",
            "identifier": "18091",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CRIME VICTIMS",
            "identifier": "8903272",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PREMERA",
            "identifier": "135",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3147709",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "L&I ER DOC NUMBER",
            "identifier": "18090",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PRO FEE",
            "identifier": "G000800088",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CD1667",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Summit Pacific Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Elma, WA

Sources for this page

Verify at the official NPI Registry.