Basic Information
Provider Information
NPI: 1700803418
EntityType: 2
ReplacementNPI:  
OrganizationName: DIGNITY HEALTH MEDICAL FOUNDATION
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: MERCY MEDICAL GROUP, A SERVICE OF DIGNITY HEALTH MEDICAL FOUNDATION
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 742016
Address2:  
City: LOS ANGELES
State: CA
PostalCode: 900742016
CountryCode: US
TelephoneNumber: 9163792840
FaxNumber: 9168591106
Practice Location
Address1: 3000 Q ST
Address2:  
City: SACRAMENTO
State: CA
PostalCode: 958167058
CountryCode: US
TelephoneNumber: 9167333397
FaxNumber: 9167335385
Other Information
ProviderEnumerationDate: 07/17/2006
LastUpdateDate: 11/18/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: HYLEN
AuthorizedOfficialFirstName: THERESA
AuthorizedOfficialMiddleName: M
AuthorizedOfficialTitleorPosition: CHIEF FINANCIAL OFFICER
AuthorizedOfficialTelephone: 9168512559
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: DIGNITY HEALTH MEDICAL FOUNDATION
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 11/18/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM1300X  Y Ambulatory Health Care FacilitiesClinic/CenterMulti-Specialty

ID Information
IDTypeStateIssuerDescription
GRE00027005CA MEDICAID
ZZZ29477Z01 BSCA - ALLERGYOTHER
ZZZ29475X01 BSCA - GASTROENTEROLOGYOTHER
ZZZ29478Z01 BSCA - GENERAL SURGERYOTHER
GR005015005CA MEDICAID
ZZZ29339Z01 BSCA - PEDIATRICSOTHER
ZZZ29468Z01 BSCA - RHEUMATOLOGYOTHER
ZZZ26345Z01 BSCA - ENDOCRINOLOGYOTHER
ZZZ29336Z01 BSCA - FAMILY PRACTICEOTHER
ZZZ29478Z01 BSCA - URGENT CAREOTHER
GSD00084005CA MEDICAID
ZZZ28115Z01 BSCA - DOWNTOWNOTHER
ZZZ29337Z01 BSCA - INTERNAL MEDICINEOTHER
ZZZ29338301 BSCA - OBGYNOTHER
ZZZ29474Z01 BSCA - RADIOLOGYOTHER
ZZZ29472Z01 BSCA - UROLOGYOTHER
KVY01CABLUE CROSSOTHER


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