Basic Information
| Provider Information | |||||||||
| NPI: | 1477671535 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MERCY MEDICAL CENTER REDDING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 496009 | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960496009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302256300 | ||||||||
| FaxNumber: | 5302257278 | ||||||||
| Practice Location | |||||||||
| Address1: | 2175 ROSALINE AVE | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960012509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302256300 | ||||||||
| FaxNumber: | 5302257278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 06/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIRANDA | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5302256121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 230000024 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 56236041196001B001 | 01 | CA | CHAMPUS TRICARE MATERNITY | OTHER | GR0030730 | 05 | CA | MEDICAID | CGP166510 | 05 | CA | MEDICAID | 562360411960010000 | 01 | CA | CHAMPUS TRICARE ACUTE | OTHER | ZZZC4504Z | 01 | CA | BLUE SHIELD OF CA ACUTE | OTHER | ZZZ56416Z | 01 | CA | BLUE SHIELD CA MATERNITY | OTHER | ZZZ94524Z | 01 | CA | BLUE SHIELD CA AMBULANCE | OTHER | ZZZC4504Z | 01 | CA | BLUE SHIELD | OTHER | 562360411 | 01 | CA | IRS FTN NUMBER | OTHER | ZZR00280G | 05 | CA | MEDICAID | ZZZ56417Z | 01 | CA | BLUE SHIELD CA FAMILY HTH | OTHER | 050280B000000 | 01 | CMS SECTION 1011 | OTHER | 562360411960010002 | 01 | CA | CHAMPUS TRICARE AMBULANCE | OTHER | 56236041196001A001 | 01 | AR | CHAMPUS TRICARE FAMILY HH | OTHER | GR0040290 | 05 | CA | MEDICAID | HSP40280G | 05 | CA | MEDICAID | MTE00180F | 05 | CA | MEDICAID |