Basic Information
| Provider Information | |||||||||
| NPI: | 1023331303 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CHARLES HEALTH SYSTEM, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. CHARLES MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5579 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977085579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824321 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 NE NEFF RD | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2010 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | WELANDER | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5413824321 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500625168 | 05 | OR | MEDICAID |