Basic Information
| Provider Information | |||||||||
| NPI: | 1518438712 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE SAINT JOHNS MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ONE MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 SANTA MONICA BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105827312 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2020 SANTA MONICA BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105827312 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2018 | ||||||||
| LastUpdateDate: | 02/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY FOR ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.