NPIMap

Organization Active NPI

Columbia Gorge Medical Center PC

Doing business as Columbia Gorge Family Medicine

  • Rural Health Clinic/Center
  • Hood River, OR
National Provider Identifier
1821364944
Registry record updated Mar 23, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
COLUMBIA GORGE MEDICAL CENTER PC
Doing business as
Columbia Gorge Family Medicine
Practice address
1750 12TH St
Hood River, OR 97031-9540
Phone
(541) 386-5070
Fax
(541) 386-7190
NPI assigned
Mar 23, 2012
Last updated
Mar 23, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 23, 2012

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

Authorized official

Name
Dr. Kristen Gail Dillon, M.D.
Title
Managing Partner
Phone
(541) 386-5070

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

1750 12TH St
Hood River, OR 97031-9540

Mailing address

1750 12TH St
Hood River, OR 97031-9540
Phone (541) 386-5070

Other names 1

  • Columbia Gorge Family Medicine Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120612000407 OR Part A Provider - Rural Health Clinic 8628066115 Practice locations: Hood River, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1821364944. Details of each certification follow.

Rural health clinic certification: CCN 383882

Legal name
COLUMBIA GORGE MEDICAL CENTER PC
Doing business as
COLUMBIA GORGE FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 27, 2012
Last certification
Mar 27, 2019
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Mar 13, 1991 in OR
Enrollment address
1750 12TH St
Hood River, OR 97031-9540

Other NPIs with the same Medicare PAC ID 1

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Kelsey Phillips Individual Operational/Managerial ControlClinic Administrator May 1, 2021
Tyler T Gray Individual 5% Or Greater Direct Ownership Interest Mar 1, 2015 20%
Peter Ward Benziger Individual 5% Or Greater Direct Ownership Interest Nov 1, 2018 20%
Matthew B Sperry Individual 5% Or Greater Direct Ownership Interest Apr 1, 2019
Frank Quevedo Individual W-2 Managing EmployeeAd; May 1, 2021
Anthony S Gay Individual Corporate OfficerSecretary Apr 8, 2011 25%
Jessica Andrea Porter Individual 5% Or Greater Direct Ownership Interest Nov 1, 2018 20%

Owners & managing parties with NPI records 5

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

Practitioners & affiliated clinicians

Practitioners 20

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 20

NPI Registry JSON

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

{
    "created_epoch": "1332460800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1332460800000",
    "number": "1821364944",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1750 12TH ST",
            "city": "HOOD RIVER",
            "state": "OR",
            "postal_code": "970319540",
            "telephone_number": "541-386-5070",
            "fax_number": "541-386-7190"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1750 12TH ST",
            "city": "HOOD RIVER",
            "state": "OR",
            "postal_code": "970319540",
            "telephone_number": "541-386-5070",
            "fax_number": "541-386-7190"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COLUMBIA GORGE MEDICAL CENTER PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-03-23",
        "last_updated": "2012-03-23",
        "status": "A",
        "authorized_official_last_name": "DILLON",
        "authorized_official_first_name": "KRISTEN",
        "authorized_official_middle_name": "GAIL",
        "authorized_official_title_or_position": "MANAGING PARTNER",
        "authorized_official_telephone_number": "541-386-5070",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Columbia Gorge Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hood River, OR

Sources for this page

Verify at the official NPI Registry.