Basic Information
| Provider Information | |||||||||
| NPI: | 1750788667 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARONDELET HEALTH NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BRIDGES GEROPSYCHIATRIC PROGRAM AT ST. MARY'S HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2202 N FORBES BLVD | ||||||||
| Address2: | ATTN: MANAGED CARE | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857451412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208727700 | ||||||||
| FaxNumber: | 5208727246 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 W SAINT MARYS RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857452623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208722058 | ||||||||
| FaxNumber: | 5208722049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2014 | ||||||||
| LastUpdateDate: | 11/21/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STRAUSS | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5208727790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | H0011 | AZ | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 020339 | 05 | AZ | MEDICAID |