Basic Information
| Provider Information | |||||||||
| NPI: | 1447393152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. ROSE DOMINICAN HOSPITAL, ROSE DE LIMA CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3033 N 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023072420 | ||||||||
| FaxNumber: | 6027989655 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 E LAKE MEAD PKWY | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890155575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025642622 | ||||||||
| FaxNumber: | 7026165511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALTERS | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7026165507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 659HOS-12 | CA | N | Hospital Units | Rehabilitation Unit | 282N00000X | 659HOS-12 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1202873 | 05 | NV | MEDICAID | 880059427890150000 | 01 | TRICARECHAMPUS | OTHER | NV6055 | 01 | NV | BLUE CROSS BLUE SHIELD | OTHER | 880059427890150008 | 01 | NV | TRICARECHAMPUS | OTHER | 68477 | 01 | NV | AETNA | OTHER | 1102873 | 05 | NV | MEDICAID | 190750100 | 01 | NV | US DEPT OF LABOR | OTHER | 1002873 | 05 | NV | MEDICAID | 880059427 | 01 | IRS | OTHER |