Basic Information
| Provider Information | |||||||||
| NPI: | 1477519908 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUTTER HEALTH PACIFIC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KAHI MOHALA HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91-2301 FORT WEAVER RD | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967063602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086718511 | ||||||||
| FaxNumber: | 8086772570 | ||||||||
| Practice Location | |||||||||
| Address1: | 91-2301 FORT WEAVER RD | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967063602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086718511 | ||||||||
| FaxNumber: | 8086772570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8086718511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 33-H | HI | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0006220245 | 01 | HI | AETNA | OTHER | 508129 | 05 | HI | MEDICAID |