Provider Demographics
NPI:1568469997
Name:SAN GORGONIO MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SAN GORGONIO MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PT. FIN. SVC.
Authorized Official - Prefix:MS
Authorized Official - First Name:MAYDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-769-2170
Mailing Address - Street 1:600 N HIGHLAND SPRINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-3046
Mailing Address - Country:US
Mailing Address - Phone:951-845-1121
Mailing Address - Fax:951-769-0431
Practice Address - Street 1:600 N HIGHLAND SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3046
Practice Address - Country:US
Practice Address - Phone:951-845-1121
Practice Address - Fax:951-769-0431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250001199282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSC30054GOtherMEDICAID IP PROV
CAZZT40054GOtherMEDICAID OP PROVIDER NO
CA050054OtherMEDICARE PROVIDER NUMBER
CAZZT30054GMedicaid
CAZZT40054GMedicaid
CAZZT30054GOtherMEDICAID INPT PROV NUMBER
CAZZT30054GMedicaid