Basic Information
| Provider Information | |||||||||
| NPI: | 1285936807 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARK TWAIN ST. JOSEPH'S HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 768 MT RANCH RD. | ||||||||
| Address2: | |||||||||
| City: | SAN ANDREAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097543521 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1919 VISTA DEL LAGO | ||||||||
| Address2: | |||||||||
| City: | VALLEY SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097729538 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2010 | ||||||||
| LastUpdateDate: | 12/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | SHELDEN | ||||||||
| AuthorizedOfficialFirstName: | ROY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MEDICAL STAFF | ||||||||
| AuthorizedOfficialTelephone: | 2097543521 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | 19190 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.