Basic Information
Provider Information | |||||||||
NPI: | 1518085430 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DIGNITY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCY MEDICAL CENTER MT. SHASTA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P O BOX 469009 | ||||||||
Address2: |   | ||||||||
City: | REDDING | ||||||||
State: | CA | ||||||||
PostalCode: | 960496009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302256300 | ||||||||
FaxNumber: | 5302257278 | ||||||||
Practice Location | |||||||||
Address1: | 914 PINE ST | ||||||||
Address2: |   | ||||||||
City: | MOUNT SHASTA | ||||||||
State: | CA | ||||||||
PostalCode: | 960672143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5309266111 | ||||||||
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 | 282NC0060X | 230000015 | CA | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 050419B000000 | 01 |   | CMS SECTION 1011 | OTHER | 721561129 | 01 | CA | IRS FTN NUMBER | OTHER | HSP40419I | 05 | CA |   | MEDICAID | ZZZC4704Z | 01 | CA | BLUE SHIELD OF CA | OTHER | 721561129960670000 | 01 | CA | CHAMPUS TRICARE ACUTE | OTHER | 721561129960670001 | 01 | CA | CHAMPUS TRICARE SWING BED | OTHER | HSP30419I | 05 | CA |   | MEDICAID |