Basic Information
| Provider Information | |||||||||
| NPI: | 1124026273 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE SAINT JOHN'S HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1328 22ND ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108295511 | ||||||||
| FaxNumber: | 3103156135 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 SANTA MONICA BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108295511 | ||||||||
| FaxNumber: | 3103156135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 02/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY - ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 930000158 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | ZZT30290F | 05 | CA | MEDICAID | ZZT40290F | 05 | CA | MEDICAID |