Basic Information
| Provider Information | |||||||||
| NPI: | 1619271756 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. CHARLES HEALTH SYSTEM, INC. | ||||||||
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| OtherOrganizationName: | ST. CHARLES ANTI-COAG CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1420 | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977560400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415266556 | ||||||||
| FaxNumber: | 5417063765 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 NE WYATT CT | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417064701 | ||||||||
| FaxNumber: | 5417064751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2011 | ||||||||
| LastUpdateDate: | 01/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | SHEPARD | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP FINANCE / CFO | ||||||||
| AuthorizedOfficialTelephone: | 5417067707 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500625168 | 05 | OR | MEDICAID |