Provider Demographics
NPI:1649681560
Name:MOSAIC MEDICAL
Entity type:Organization
Organization Name:MOSAIC MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAASE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:541-447-0707
Mailing Address - Street 1:600 SW COLUMBIA ST
Mailing Address - Street 2:SUITE 6210
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1099
Mailing Address - Country:US
Mailing Address - Phone:541-323-3181
Mailing Address - Fax:541-706-9895
Practice Address - Street 1:2150 NE DAGGETT LN
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6560
Practice Address - Country:US
Practice Address - Phone:541-323-3850
Practice Address - Fax:541-383-1883
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOSAIC MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-13
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182960Medicaid