Basic Information
Provider Information | |||||||||
NPI: | 1477587632 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROVIDENCE HOLY CROSS MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 31001-3017 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911103017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103037143 | ||||||||
FaxNumber: | 3103037575 | ||||||||
Practice Location | |||||||||
Address1: | 15031 RINALDI ST | ||||||||
Address2: |   | ||||||||
City: | MISSION HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 91345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8183658051 | ||||||||
FaxNumber: | 8184964565 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 03/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON | ||||||||
AuthorizedOfficialFirstName: | DONALD | ||||||||
AuthorizedOfficialMiddleName: | WAYNE | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY FOR ENROLLMENT | ||||||||
AuthorizedOfficialTelephone: | 4255255392 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | ZZT30278G | 05 | CA |   | MEDICAID | ZZT40278G | 05 | CA |   | MEDICAID | HSC30278G | 05 | CA |   | MEDICAID | ZZZD1940Z | 01 | CA | BLUE SHIELD PROV# | OTHER | 050278 | 01 | CA | BLUE CROSS PROV# | OTHER |