Basic Information
| Provider Information | |||||||||
| NPI: | 1215903018 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY MEMORIAL HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY MEMORIAL HOSPITAL OF SAN BUENA VENTURA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 N BRENT ST | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930032809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056525011 | ||||||||
| FaxNumber: | 8055853007 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 N BRENT ST | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930032809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056525011 | ||||||||
| FaxNumber: | 8055853007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 12/19/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILDE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 8056525011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSC30394F | 05 | CA | MEDICAID | ZZZA5603Z | 01 | CA | BLUE SHIELD | OTHER | ZZT40394F | 05 | CA | MEDICAID | RHM08609F | 05 | CA | MEDICAID | RHM18553H | 05 | CA | MEDICAID | ZZZ53994Z | 01 | CA | BLUE SHIELD | OTHER | RHM08608F | 05 | CA | MEDICAID | 050394 | 01 | CA | BLUE CROSS PROVIDER NO | OTHER |