Provider Demographics
NPI:1619271756
Name:ST. CHARLES HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:ST. CHARLES HEALTH SYSTEM, INC.
Other - Org Name:ST. CHARLES ANTI-COAG CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP FINANCE / CFO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-706-7707
Mailing Address - Street 1:PO BOX 1420
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0400
Mailing Address - Country:US
Mailing Address - Phone:541-526-6556
Mailing Address - Fax:541-706-3765
Practice Address - Street 1:2100 NE WYATT CT
Practice Address - Street 2:SUITE 103
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7702
Practice Address - Country:US
Practice Address - Phone:541-706-4701
Practice Address - Fax:541-706-4751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500625168Medicaid
OR500625168Medicaid