1730830365 NPI number — MOSAIC MEDICAL

Table of content: (NPI 1730830365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730830365 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:
Provider Other Organization Name Type Code:
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:
1730830365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2022
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 STE 6150
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:
97702-1099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-383-3005
Provider Business Mailing Address Fax Number:
541-383-1883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 NE A ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADRAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97741-1842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-383-3005
Provider Business Practice Location Address Fax Number:
541-383-1883
Provider Enumeration Date:
01/14/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SURPLUS
Authorized Official First Name:
BOBBI
Authorized Official Middle Name:
JOLYNE
Authorized Official Title or Position:
REVENUE CYCLE MANAGER
Authorized Official Telephone Number:
541-408-9486

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0003755 . This is a "PHARMACY BOARD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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