Provider Demographics
NPI:1629627203
Name:MOSAIC MEDICAL
Entity Type:Organization
Organization Name:MOSAIC MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BOBBI
Authorized Official - Middle Name:JOLYNE
Authorized Official - Last Name:SURPLUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-408-9486
Mailing Address - Street 1:600 SW COLUMBIA ST STE 6210
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1099
Mailing Address - Country:US
Mailing Address - Phone:541-408-9486
Mailing Address - Fax:541-647-2793
Practice Address - Street 1:375 NW BEAVER ST STE 101
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1802
Practice Address - Country:US
Practice Address - Phone:541-408-9486
Practice Address - Fax:541-647-2793
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOSAIC MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)