Basic Information
| Provider Information | |||||||||
| NPI: | 1396725677 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARIN GENERAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8010 | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949128010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159257100 | ||||||||
| FaxNumber: | 4159257933 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 BON AIR RD | ||||||||
| Address2: | |||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949041702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159257100 | ||||||||
| FaxNumber: | 4159257933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 08/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | DOMANICO | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXEC. OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4159257100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 110000361 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSM003606 | 05 | CA | MEDICAID |