=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285936807
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK TWAIN ST. JOSEPH'S HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2010
-----------------------------------------------------
Last Update Date | 12/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1919 VISTA DEL LAGO
-----------------------------------------------------
City | VALLEY SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-772-9538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 768 MT RANCH RD.
-----------------------------------------------------
City | SAN ANDREAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-754-3521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF MEDICAL STAFF
-----------------------------------------------------
Name | MR. ROY SHELDEN
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 209-754-3521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 19190
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------