Basic Information
| Provider Information | |||||||||
| NPI: | 1528199502 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NORTHRIDGE HOSPITAL MEDICAL CENTER - SHERMAN WAY CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3215 PROSPECT PARK DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956706017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168611102 | ||||||||
| FaxNumber: | 9168617707 | ||||||||
| Practice Location | |||||||||
| Address1: | 14500 SHERMAN CIR | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914053052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188858500 | ||||||||
| FaxNumber: | 8188855439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 09/20/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8188855321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 930000169 | CA | N | Hospital Units | Psychiatric Unit | 314000000X | 930000169 | CA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 282N00000X | 930000169 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | ZZT40299J | 05 | CA | MEDICAID | HSC30299J | 05 | CA | MEDICAID | 870692259914050000 | 01 | CA | WPS TRICARE | OTHER | LTC70143F | 05 | CA | MEDICAID | NOHS | 01 | CA | UNIVERSAL | OTHER | HSM30299J | 05 | CA | MEDICAID | ZZT30299J | 05 | CA | MEDICAID | ZZZA1962Z | 01 | CA | BLUE SHIELD | OTHER | 0777367 | 01 | CA | AETNA | OTHER | 870692259 | 01 | CA | IRS | OTHER |