1144215542 NPI number — ST. CHARLES HEALTH SYSTEM, INC.

Table of content: (NPI 1144215542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144215542 NPI number — ST. CHARLES HEALTH SYSTEM, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. CHARLES HEALTH SYSTEM, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1144215542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6095
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97708-6095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-382-4321
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2275 NE DOCTORS DR STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97701-6324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-706-7796
Provider Business Practice Location Address Fax Number:
541-706-4996
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SWAFFORD
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
541-382-4321

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  14-1457 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4700002 . This is a "CLEAR CHOICE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 292836 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 400072 . This is a "COIHS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 239482000001 . This is a "PROVIDENCE HEALTH PLAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 081408000 . This is a "BLUE CROSS OF OREGON" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: P328701 . This is a "PACIFICSOURCE HEALTH PLAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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