Provider Demographics
NPI:1417143413
Name:CASA GRANDE COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:CASA GRANDE COMMUNITY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:MARTY
Authorized Official - Last Name:DERNIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-381-6462
Mailing Address - Street 1:1800 E FLORENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-5303
Mailing Address - Country:US
Mailing Address - Phone:520-381-6921
Mailing Address - Fax:520-381-6976
Practice Address - Street 1:1676 E MCMURRAY BLVD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-6014
Practice Address - Country:US
Practice Address - Phone:520-316-0688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ030016Medicare Oscar/Certification