Basic Information
| Provider Information | |||||||||
| NPI: | 1023117751 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CHARLES HEALTH SYSTEM, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. CHARLES MEDICAL SUPPLY - BEND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5579 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977085579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415163866 | ||||||||
| FaxNumber: | 5415163877 | ||||||||
| Practice Location | |||||||||
| Address1: | 2042 NE WILLIAMSON CT | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977013760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417066905 | ||||||||
| FaxNumber: | 5417066906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | SHEPARD | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP FINANCE / CFO | ||||||||
| AuthorizedOfficialTelephone: | 5417067707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 500625168 | 05 | OR | MEDICAID |