Provider Demographics
NPI:1235290818
Name:COMMUNITY HOSPITAL OF SAN BERNARDINO
Entity Type:Organization
Organization Name:COMMUNITY HOSPITAL OF SAN BERNARDINO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDENBOSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-881-7196
Mailing Address - Street 1:1805 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1217
Mailing Address - Country:US
Mailing Address - Phone:909-887-6333
Mailing Address - Fax:909-806-1017
Practice Address - Street 1:1805 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1217
Practice Address - Country:US
Practice Address - Phone:909-887-6333
Practice Address - Fax:909-806-1017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000198273R00000X, 282N00000X, 314000000X
CAHSP379393336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273R00000XHospital UnitsPsychiatric Unit
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSC30089FMedicaid
CAHSM30089FMedicaid
CALTC70044FMedicaid
CAPHB379390Medicaid
CAZZT40089FMedicaid
5615375OtherNCPDP
CAZZZA3608ZOtherBLUE SHIELD
CAHSC30089FMedicaid
CAZZT40089FMedicaid
CA=========924110002OtherWPSTRICARE
5615375OtherNCPDP
CA555522Medicare Oscar/Certification