Provider Demographics
NPI:1588902860
Name:MOSAIC MEDICAL MOBILE UNIT
Entity type:Organization
Organization Name:MOSAIC MEDICAL MOBILE UNIT
Other - Org Name:
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:FNP
Authorized Official - Phone:541-447-0707
Mailing Address - Street 1:375 NW BEAVER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1802
Mailing Address - Country:US
Mailing Address - Phone:541-447-0707
Mailing Address - Fax:
Practice Address - Street 1:2084 NE PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6077
Practice Address - Country:US
Practice Address - Phone:541-383-3005
Practice Address - Fax:541-383-1883
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOSAIC MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-22
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182960Medicaid
OR381886Medicare Oscar/Certification