Provider Demographics
NPI:1205002938
Name:MARK TWAIN MEDICAL CENTER
Entity Type:Organization
Organization Name:MARK TWAIN MEDICAL CENTER
Other - Org Name:FAMILY MEDICAL CENTER - SAN ANDREAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-754-2614
Mailing Address - Street 1:768 MOUNTAIN RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-9707
Mailing Address - Country:US
Mailing Address - Phone:209-754-3521
Mailing Address - Fax:
Practice Address - Street 1:704 MOUNTAIN RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9707
Practice Address - Country:US
Practice Address - Phone:209-754-3521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARK TWAIN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-02
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058940Medicare Oscar/Certification