Provider Demographics
NPI:1861434615
Name:GRANDE RONDE HOSPITAL
Entity type:Organization
Organization Name:GRANDE RONDE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-963-1469
Mailing Address - Street 1:612 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1248
Mailing Address - Country:US
Mailing Address - Phone:541-963-9123
Mailing Address - Fax:541-962-0695
Practice Address - Street 1:612 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1248
Practice Address - Country:US
Practice Address - Phone:541-963-9123
Practice Address - Fax:541-962-0695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR394792208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067801Medicaid