Basic Information
| Provider Information | |||||||||
| NPI: | 1609979707 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERICAN HOSPITAL MANAGEMENT CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MAD RIVER COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1115 | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955181115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078223621 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3800 JANES RD | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955214742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078223621 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7078227220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | PENDING | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1609979707 | 05 | CA | MEDICAID |