Provider Demographics
NPI:1508968819
Name:MARK TWAIN MEDICAL CENTER
Entity Type:Organization
Organization Name:MARK TWAIN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIVERS
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:209-754-2675
Practice Address - Street 1:768 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:209-754-2675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000058282N00000X
282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR00366GMedicaid
CALTC30366GMedicaid
ZZZC0502ZOtherBLUE SHIELD OF CA
233520100OtherDEPT. OF LABOR - WC
CAHSP40366GMedicaid
=========952490000OtherWPS TRICARE
CAHSP40366GMedicaid
=========OtherIRS - TAX ID
CALTC30366GMedicaid
ZZZC0502ZOtherBLUE SHIELD OF CA