Basic Information
| Provider Information | |||||||||
| NPI: | 1356389878 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MERCY HOSPITAL OF FOLSOM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3215 PROSPECT PARK DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956706017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168611102 | ||||||||
| FaxNumber: | 9168617707 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 CREEKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169837400 | ||||||||
| FaxNumber: | 9169837406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 09/10/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROGNESS | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9169847379 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 030000372 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP00414H | 05 | CA | MEDICAID | HSP40414H | 05 | CA | MEDICAID | HSC00414H | 05 | CA | MEDICAID | ZZZC3408Z | 01 | BLUE SHIELD OF CA | OTHER | 942761692956300000 | 01 | WPS TRICARE | OTHER | 196456500 | 01 | CA | DEPT. OF LABOR - WC | OTHER | 942761692 | 01 | IRS - PRE-MERGER TAX ID | OTHER | CGP008385 | 05 | CA | MEDICAID |