1679811954 NPI number — MOSAIC MEDICAL

Table of content: (NPI 1679811954)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679811954 NPI number — MOSAIC MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOSAIC MEDICAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MOSAIC MEDICAL PRINEVILLE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679811954
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 SW COLUMBIA ST
Provider Second Line Business Mailing Address:
SUITE 6210
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97702-1099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-447-0707
Provider Business Mailing Address Fax Number:
541-447-0708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 NW BEAVER ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PRINEVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97754-1802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-447-0707
Provider Business Practice Location Address Fax Number:
541-383-1883
Provider Enumeration Date:
01/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HAASE
Authorized Official First Name:
MEGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
541-447-0707

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 182960 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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