Provider Demographics
NPI:1538179635
Name:ST BERNARD COMMUNITY HOSPITAL CORPORATION
Entity type:Organization
Organization Name:ST BERNARD COMMUNITY HOSPITAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-238-3300
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-0590
Mailing Address - Country:US
Mailing Address - Phone:870-238-3300
Mailing Address - Fax:870-238-7432
Practice Address - Street 1:732 E ELDRIDGE ST
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396
Practice Address - Country:US
Practice Address - Phone:870-238-3300
Practice Address - Fax:870-238-7432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR3891251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143518753Medicaid
AR145227754Medicaid
AR142758514Medicaid
AR17048OtherBLUE CROSS HOME HEALTH