Basic Information
| Provider Information | |||||||||
| NPI: | 1528101284 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. ROSE DOMINICAN HOSPITAL, SAN MARTIN CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 8280 W WARM SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891133612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024928000 | ||||||||
| FaxNumber: | 7026165511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALTERS | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7026165507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 4576HOS0 | NV | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 383730230 | 01 | IRS | OTHER | 100511422 | 05 | NV | MEDICAID | 100511423 | 05 | NV | MEDICAID | 100511424 | 05 | NV | MEDICAID |