NPIMap

Organization Active NPI

Tri-State Memorial Hospital

  • Critical Access Hospital
  • Clarkston, WA
National Provider Identifier
1760485221
Registry record updated Mar 24, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access HospitalTaxonomy code 282NC0060X
License
H-108 Issued in WA
Legal business name
TRI-STATE MEMORIAL HOSPITAL
Practice address
1221 Highland Ave
Clarkston, WA 99403-2829
Phone
(509) 758-5511
Fax
(509) 751-9406
NPI assigned
May 27, 2005
Last updated
Mar 24, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 24, 2011

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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital 282NC0060X H-108 WA Primary

Addresses

Primary practice location

1221 Highland Ave
Clarkston, WA 99403-2829

Mailing address

1221 Highland Ave
Clarkston, WA 99403-2829
Phone (509) 758-5511

Other identifiers 4

IdentifierTypeStateIssuer
003308004MedicaidWA
003110900MedicaidID
000010002128OtherREGENCE BLUE SHIELD OF IDAHO
00620OtherBLUE CROSS OF IDAHO

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20061104000320 WA Part A Provider - Critical Access Hospital 4082502422 Receives reassigned benefits from 157 practitioners
1 other NPI on this enrollment
Practice locations: Clarkston, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1760485221. Details of each certification follow.

Hospital certification: CCN 501332

Legal name
TRI-STATE MEMORIAL HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Aug 1, 2004
Last certification
Nov 29, 2012
Beds
25
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Incorporated
Apr 19, 1999 in WA
Enrollment address
1119 Highland Ave
Ste 4
Clarkston, WA 99403-2836
Main/Primary Hospital Location

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

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 1

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Tri-State Memorial HospitalCCN 501332 · All quality measures
Overall star rating
4 of 5
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory
Tax ID family
Tri State Memorial Hospital3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Locations

1119 Highland Ave
Ste 1
Clarkston, WA 99403
Phone (509) 254-2722

1119 Highland Ave
Ste 11
Clarkston, WA 99403
Phone (509) 758-4450

1221 Highland Ave
Ste 5
Clarkston, WA 99403

1267 Belmont Way
Clarkston, WA 99403
Phone (509) 751-1500

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
John Seeh Individual Corporate Director May 1, 2012
Eddie Wayne Day Individual Corporate Director Jun 24, 2004
Kimberly Clift Individual W-2 Managing Employee Apr 1, 2021
Donald McQuary Individual Corporate Director Jun 24, 2004
Debra Ausman Individual Corporate Director May 1, 2012
Dawn Larae Merrill Individual Corporate Director Jun 24, 2004
Steve Claassen Individual Corporate Director Nov 19, 2007
Kevin David Hagen Individual Corporate Director Mar 1, 2006
Sandy K Blume Individual W-2 Managing Employee May 1, 2012
Richard Flerchinger Individual Corporate Director Jun 24, 2004
Rhonda Mason Individual Corporate Director Dec 8, 1999
W-2 Managing Employee Dec 8, 1999
Daniel Klaveano Individual Corporate Director May 1, 2012
Scott Arnone Individual Corporate Director Jun 24, 2004
Michael Martin Individual Corporate Director Jun 24, 2004

Practitioners & affiliated clinicians

Practitioners 159

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 159

Affiliated clinicians 191

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

View all 191

NPI Registry JSON

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

{
    "created_epoch": "1117152000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1300924800000",
    "number": "1760485221",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1221 HIGHLAND AVE",
            "city": "CLARKSTON",
            "state": "WA",
            "postal_code": "994032829",
            "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": "1221 HIGHLAND AVE",
            "city": "CLARKSTON",
            "state": "WA",
            "postal_code": "994032829",
            "telephone_number": "509-758-5511",
            "fax_number": "509-751-9406"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRI-STATE MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-05-27",
        "last_updated": "2011-03-24",
        "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": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "WA",
            "license": "H-108",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003308004",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003110900",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD OF IDAHO",
            "identifier": "000010002128",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF IDAHO",
            "identifier": "00620",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Clarkston, WA

Sources for this page

Verify at the official NPI Registry.