Basic Information
| Provider Information | |||||||||
| NPI: | 1508968819 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARK TWAIN MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 768 MOUNTAIN RANCH RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANDREAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952499707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097543521 | ||||||||
| FaxNumber: | 2097542675 | ||||||||
| Practice Location | |||||||||
| Address1: | 768 MOUNTAIN RANCH RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANDREAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952499707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097543521 | ||||||||
| FaxNumber: | 2097542675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | CHIVERS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2097542614 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 030000058 | CA | N | Hospitals | General Acute Care Hospital | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | ZZR00366G | 05 | CA | MEDICAID | LTC30366G | 05 | CA | MEDICAID | ZZZC0502Z | 01 | BLUE SHIELD OF CA | OTHER | 233520100 | 01 | DEPT. OF LABOR - WC | OTHER | HSP40366G | 05 | CA | MEDICAID |