Organization
PULLMAN REGIONAL HOSPITAL CLINIC NETWORK LLC
Active
Other names
Palouse Pediatrics - Moscow
Organization subpart
No
Provider details
NPI number
Authorized official
GROVER 'PETE' C PETERS III (CLINIC ADMINISTRATOR)
(509) 332-6139
Entity
Organization
Contact information
Practice address
1420 S BLAINE ST STE 5, MOSCOW, ID 83843-3973
(208) 882-2247
(509) 336-7482
Mailing address
840 SE BISHOP BLVD STE 101, PULLMAN, WA 99163-5502
(509) 332-6139
(509) 332-6579
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
—
—
2084P0800X
Psychiatry Physician
—
—
261QR1300X
Rural Health Clinic/Center
Primary
13-3860
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
13-3860
CMS CERTIFICATION
ID
01
—
1369068
MEDICARE PTAN
ID
Enumeration date
12/01/2011
Last updated
06/26/2015
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