Basic Information
| Provider Information | |||||||||
| NPI: | 1861009672 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORCAL HEALTHCONNECT LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALDSBURG HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31001-3085 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911103085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074316500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1375 UNIVERSITY ST | ||||||||
| Address2: | |||||||||
| City: | HEALDSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954483382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074316500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2020 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST SEC FOR ENROLL DIR REIMB STRAT | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
No ID Information.