Basic Information
| Provider Information | |||||||||
| NPI: | 1033311824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY MEDICAL GROUP, A SERVICE OF DIGNITY HEALTH MEDICAL FOUNDATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60000 | ||||||||
| Address2: | FILE #72938 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941602938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166918500 | ||||||||
| FaxNumber: | 9166918599 | ||||||||
| Practice Location | |||||||||
| Address1: | 9394 BIG HORN BLVD | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957587977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333397 | ||||||||
| FaxNumber: | 9167335385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HYLEN | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9168512559 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH MEDICAL FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 195 | 01 | HN COMMERCIAL | OTHER | 983 | 01 | HN MEDICARE | OTHER | KYJ | 01 | BCCA | OTHER | 0019838 | 01 | CIGNA | OTHER | ZZZ69884Z | 01 | BSCA | OTHER |