MID-COLUMBIA FAMILY PHYSICIANS, P.S.

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Company Details

Legal Name:	MID-COLUMBIA FAMILY PHYSICIANS, P.S.
Jurisdiction:	WASHINGTON
Entity Type:	WA PROFESSIONAL SERVICE CORPORATION
Category:	DOMESTIC ENTITY
Status:	Voluntarily Dissolved
Formation/ Registration Date:	October 5th 1981
Date of Dissolution:	September 30th 2024
Expiration date:	31 Oct 2024
UBI Number:	600 416 746
ZIP code:	98672
City:	White Salmon
County:	KLICKITAT
Home State:	WASHINGTON
Principal Office Street Address:	65371 HIGHWAY 14, WHITE SALMON, WA, 98672, UNITED STATES
Principal Office Mailing Address:	PO BOX 1519, WHITE SALMON, WA, 98672-1519, UNITED STATES
Supporting healthcare providers fighting with COVID-19:	$743,393

Contact Details

E-Mail:	KUPCHINE@NORTHSHORE-MEDICAL.COM
Phone Number:	+1 509-493-2133

Nature of Business

HEALTH CARE

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Registered Agent Information

Name	Role	Address
R. ALLEN LEBERGE	Registered Agent	65371 HIGHWAY 14, WHITE SALMON, WA, 98672, UNITED STATES

Key Officers & Management

Name	Role
R ALLEN LABERGE	Governing Person
CHRISTOPHER FAISON	Governing Person
CHRISTOPHER SAMUELS	Governing Person
TROY WITHERRITE	Governing Person
GREGORY ZUCK	Governing Person

National Provider Identifier

NPI Number:

1083948582

Link:

View on NPI website

Authorized Person:

Name:

DR. RAYMOND J FITZSIMMONS

Role:

PRESIDENT

Phone:

5094932133

Taxonomy:

Selected Taxonomy:

261QR1300X - Rural Health Clinic/Center

Is Primary:

No

Selected Taxonomy:

207Q00000X - Family Medicine Physician

Is Primary:

Yes

Contacts:

Phone:

+1 509-493-2133

Fax:

5094939538

Form 5500 Series

Employer Identification Number (EIN):

911152824

Plan Year:

2023

Number Of Participants:

43

Plan Name:

401(K)

Sponsor's DBA Name:

NORTHSHORE MEDICAL GROUP

Sponsor's telephone number:

5094932133

File:

Plan Administrator / Signatory:

MARI MATTHIAS(Plan administrator)

Plan Year:

2023

Number Of Participants:

54

Plan Name:

401(K)

Sponsor's DBA Name:

NORTHSHORE MEDICAL GROUP

Sponsor's telephone number:

5094932133

File:

Plan Administrator / Signatory:

MARI MATTHIAS(Plan administrator)

Plan Year:

2022

Number Of Participants:

63

Plan Name:

401(K)

Sponsor's DBA Name:

NORTHSHORE MEDICAL GROUP

Sponsor's telephone number:

5094932133

File:

Plan Administrator / Signatory:

MARI MATTHIAS(Plan administrator)

Plan Year:

2021

Number Of Participants:

59

Plan Name:

401(K)

Sponsor's DBA Name:

NORTHSHORE MEDICAL GROUP

Sponsor's telephone number:

5094932133

File:

Plan Administrator / Signatory:

EMMA KUPCHIN(Plan administrator)

Plan Year:

2020

Number Of Participants:

52

Plan Name:

401(K)

Sponsor's DBA Name:

NORTHSHORE MEDICAL GROUP

Sponsor's telephone number:

5094932133

File:

Plan Administrator / Signatory:

EMMA KUPCHIN(Plan administrator)

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