Provider Demographics
NPI:1174604839
Name:GOOD SHEPHERD HEALTH CARE SYSTEM
Entity type:Organization
Organization Name:GOOD SHEPHERD HEALTH CARE SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-667-3438
Mailing Address - Street 1:610 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-6601
Mailing Address - Country:US
Mailing Address - Phone:541-667-3438
Mailing Address - Fax:541-667-3444
Practice Address - Street 1:1050 W ELM AVE
Practice Address - Street 2:SUITE #110
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2700
Practice Address - Country:US
Practice Address - Phone:541-567-3797
Practice Address - Fax:541-567-7720
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD HEALTH CARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-18
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09041207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276278Medicaid
ORR109963Medicare PIN