Basic Information
| Provider Information | |||||||||
| NPI: | 1629291745 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. MARY'S DEPARTMENT OF MEDICINE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2235 HAYES ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941171012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157505500 | ||||||||
| FaxNumber: | 4157505619 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 STANYAN ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941171079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156681000 | ||||||||
| FaxNumber: | 4157505899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 09/23/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRETTNER | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4157505726 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 220000071 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | ZZZ05047Z | 01 | BLUE SHIELD OF CA | OTHER | GR0050760 | 05 | CA | MEDICAID | 721561126 | 01 | IRS - SP TAX ID | OTHER |