Basic Information
| Provider Information | |||||||||
| NPI: | 1972749893 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILLS-PENINSULA HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUTTER MATERNITY/SURGERY CENTER SANTA CRUZ | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742738 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900742738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6506523803 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2900 CHANTICLEER AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950651816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314772210 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2008 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GATES | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO SHBA | ||||||||
| AuthorizedOfficialTelephone: | 5104507357 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 070000399 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP30714F | 05 | CA | MEDICAID | HSP40714F | 05 | CA | MEDICAID |