Basic Information
| Provider Information | |||||||||
| NPI: | 1083732853 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST. ELIZABETH COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P. O. BOX 469009 | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960496009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302256300 | ||||||||
| FaxNumber: | 5302257278 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 SISTER MARY COLUMBA DR | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960804327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305298000 | ||||||||
| FaxNumber: | 5302257278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 06/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIRANDA | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5302256121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 230000036 | CA | N | Hospital Units | Medicare Defined Swing Bed Unit | 282N00000X | 230000036 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | LTC30042G | 05 | CA | MEDICAID | ZZR00042H | 05 | CA | MEDICAID | ZZZC5202Z | 01 | CA | BLUE SHIELD OF CA ACUTE | OTHER | 721561118 | 01 | CA | IRS FTN NUMBER | OTHER | MTE00272F | 05 | CA | MEDICAID | 721561118960800002 | 01 | CA | CHAMPUS TRICARE ACUTE | OTHER | 721561118960800005 | 01 | CA | CHAMPUS TRICARE AMBULANCE | OTHER | ZZZ56412Z | 01 | CA | BLUE SHIELD CA CARDIOLOGY | OTHER | HSP40042H | 05 | CA | MEDICAID |