Provider Demographics
NPI:1790846301
Name:MARK TWAIN MEDICAL CENTER
Entity Type:Organization
Organization Name:MARK TWAIN MEDICAL CENTER
Other - Org Name:FAMILY MEDICAL CENTER - ARNOLD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
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:209-795-4193
Mailing Address - Fax:209-795-0828
Practice Address - Street 1:2182 HIGHWAY 4
Practice Address - Street 2:SUITE A-100
Practice Address - City:ARNOLD
Practice Address - State:CA
Practice Address - Zip Code:95223-9908
Practice Address - Country:US
Practice Address - Phone:209-795-4193
Practice Address - Fax:209-795-0828
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARK TWAIN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-13
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000058261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM18573FMedicaid
ZZZ61266ZOtherBLUE SHIELD OF CA
CARHM18573FMedicaid
=========952490000OtherWPS TRICARE
CA058573Medicare Oscar/Certification
=========952490000OtherWPS TRICARE