NPIMap

Organization Active NPI

Tri-State Memorial Hospital

Doing business as Tri State Medical Clinics

  • Family Medicine Physician
  • Clarkston, WA
National Provider Identifier
1932405693
Registry record updated Mar 31, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
TRI-STATE MEMORIAL HOSPITAL
Doing business as
Tri State Medical Clinics
Practice address
1221 Highland Ave
Clarkston, WA 99403-2829
Phone
(509) 758-5511
Fax
(509) 751-9406
NPI assigned
Jan 28, 2011
Last updated
Mar 31, 2011By the provider in NPPES
Organization subpart
Yes
Parent organization
TRI STATE MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 31, 2011

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

Authorized official

Name
Alex Town
Title
Cfo
Phone
(509) 758-4667

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Nephrology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RN0300X

Addresses

Primary practice location

1221 Highland Ave
Clarkston, WA 99403-2829

Mailing address

PO Box 189
Clarkston, WA 99403-0189
Phone (509) 758-5511

Other names 1

  • Tri State Medical Clinics Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040308001123 WA Part B Supplier - Clinic/Group Practice 4082502422 Receives reassigned benefits from 159 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Clarkston, WA
O20061104000320 WA Part A Provider - Critical Access Hospital 4082502422 Receives reassigned benefits from 157 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Clarkston, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1932405693. 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 on the same Medicare enrollment 2

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
Part of
Tri State Memorial Hospital

Member organizations 1

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

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 80

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 80

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": "1296172800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1301529600000",
    "number": "1932405693",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 189",
            "city": "CLARKSTON",
            "state": "WA",
            "postal_code": "994030189",
            "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": "YES",
        "parent_organization_legal_business_name": "TRI STATE MEMORIAL HOSPITAL",
        "enumeration_date": "2011-01-28",
        "last_updated": "2011-03-31",
        "status": "A",
        "authorized_official_last_name": "TOWN",
        "authorized_official_first_name": "ALEX",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "509-758-4667"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RN0300X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Nephrology",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tri State Medical Clinics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Clarkston, WA

Sources for this page

Verify at the official NPI Registry.